Clinical thinking,
spoken clearly.

1 · Prioritise risk

• I would ask specifically about sudden deterioration, severe new headache, diplopia, facial numbness or weakness, dysarthria, limb symptoms, falls, and any acute inability to mobilise. These would change the urgency and prompt immediate senior assessment.
• I would also establish the impact on driving, work, communication and falls risk, because this shapes the immediate support plan.

2 · Build the clinical picture

• I would clarify onset, progression and fluctuation; laterality; tinnitus character; vertigo versus nonspecific imbalance; otorrhoea, otalgia, pressure symptoms and previous ear disease.
• I would ask about noise exposure, ototoxic medication, vascular risk, migraine features, autoimmune symptoms and relevant family history. This keeps common, treatable and serious causes open.

3 · Examine and investigate logically

• I would perform an otological and cranial-nerve examination, look for nystagmus and assess gait only where safe. I would describe the value of formal audiometry and tympanometry rather than relying on an unstructured bedside impression.
• For asymmetrical sensorineural loss or concerning vestibular/neurological features, I would discuss appropriate imaging and specialist investigation with my supervisor, following local pathways.

4 · Communicate uncertainty

• I would say: ‘There are several possible explanations. Some are straightforward, but because this is one-sided and persistent we should investigate it properly rather than make assumptions today.’
• I would explain the next test, expected timescale, who will own the result, and that further testing does not itself mean that a serious diagnosis is likely.

5 · Close the loop

• I would document the red-flag screen, examination, working differential, investigation request and named follow-up clinician.
• I would safety-net for sudden hearing change, severe or persistent vertigo, new focal neurological symptoms, falls or a major functional decline.

1 · Establish immediate safety

• I would ask about stridor, dyspnoea, rapidly progressive swelling, inability to swallow secretions, haemoptysis, severe pain, fever or systemic deterioration. Any of these changes the urgency and requires same-day senior action.
• I would establish whether the patient is safe to go home while the pathway is arranged.

2 · Take a focused oncological and functional history

• I would clarify duration and growth, pain, dysphagia, odynophagia, voice change, referred otalgia, weight loss, night sweats and dental symptoms.
• I would sensitively ask about smoking, alcohol, previous head-and-neck treatment, HPV-related history where relevant, occupational exposure and the patient’s own understanding and fears.

3 · Explain examination and pathway

• I would describe complete head-and-neck examination, oral cavity and oropharyngeal assessment, cranial nerves and endoscopic assessment when appropriate and within competence.
• I would arrange the urgent suspected-cancer pathway and relevant investigations through the local ENT/MDT system, making clear that pathway referral is a mechanism for timely clarification, not a confirmed cancer label.

4 · Speak plainly about risk

• I would say: ‘I cannot tell you the cause of the lump from today’s examination alone. Because it has persisted, the safest approach is to organise urgent specialist assessment and tests.’
• I would pause, invite questions, avoid euphemism and check whether the patient wants a relative or supporter involved.

5 · Make follow-up explicit

• I would record a safety-net, referral route, expected contact times and a named team responsible for reviewing results.
• I would advise earlier reassessment for breathing difficulty, rapidly increasing swelling, inability to swallow, bleeding or deterioration.

1 · Listen to child and parent

• I would introduce myself to the child as well as the parent, ask what sleep is like at home and use language that matches the family’s understanding.
• I would clarify snoring frequency, witnessed apnoeas, gasping, restless sleep, enuresis, morning headaches, daytime sleepiness, hyperactivity, behaviour, school impact, growth and feeding.

2 · Identify higher-risk features

• I would ask about obesity, craniofacial or neuromuscular conditions, Down syndrome, prematurity, cardiac or respiratory disease and previous anaesthetic concerns.
• I would screen for worsening respiratory effort, marked daytime somnolence or other features requiring urgent paediatric/ENT review.

3 · Assess and plan

• I would describe a focused ENT and general examination, including growth parameters where appropriate, and explain that further assessment is guided by severity and comorbidity.
• I would involve paediatrics, sleep services or anaesthesia early where risk is higher, rather than treating every child through a single pathway.

4 · Shared decision-making

• I would say: ‘The symptoms are important and we should assess them properly. Treatment can help some children, but the right plan depends on the assessment and your child’s other health needs.’
• I would discuss benefits, limitations, alternatives and uncertainty in stages, inviting questions and giving the family time to decide.

5 · Safety-net and teach-back

• I would explain what should prompt urgent review, give written contacts where available and ask: ‘Just so I know I explained it clearly, what will you do if their breathing becomes worse?’
• I would document the parent’s questions, the child’s views where possible, risk factors and the agreed next step.

1 · Start with trauma priorities

• I would confirm mechanism, timing, loss of consciousness, anticoagulant use, alcohol/drug exposure and other facial injury.
• I would specifically ask about airway compromise, visual change, diplopia, severe headache, malocclusion, CSF-type rhinorrhoea and uncontrolled bleeding.

2 · Perform a focused assessment

• I would assess vital signs and general trauma status, inspect for deformity and soft-tissue injury, and examine the nose and septum gently within my competence.
• I would assess eyes and facial sensation where relevant, and avoid repeated or forceful examination that risks worsening pain or bleeding.

3 · Escalate safely

• I would explain that the septal finding needs urgent ENT review because delaying assessment can risk complications.
• I would keep the patient appropriately monitored, involve senior ENT care, follow local trauma and analgesia protocols, and not attempt a procedure outside my training or without supervision.

4 · Communicate the plan

• I would say: ‘The swelling inside the nose needs specialist assessment today. We are arranging that urgently because it is safer to deal with this early.’
• I would explain what will happen next, invite questions and involve a parent or supporter if appropriate.

5 · Document and safety-net

• I would record mechanism, red-flag screen, visual/airway assessment, septal findings, escalation time and named accepting clinician.
• I would ensure a clear return plan for worsening obstruction, pain, fever, bleeding or any visual symptoms.

1 · Assess current severity

• I would establish whether bleeding is active, volume and duration, recurrence, dizziness, collapse, breathlessness, chest pain and bleeding from other sites.
• I would identify whether the patient is alone, able to seek help and currently haemodynamically unwell; these answers determine immediate escalation.

2 · Clarify medicines and indication

• I would confirm the exact anticoagulant, dose, last dose, adherence, indication, renal function issues, interacting medication and any recent prescribing change.
• I would ask why the patient stopped a dose and acknowledge that their concern is understandable, while explaining that unplanned interruption can carry risk.

3 · Give safe communication

• I would say: ‘I can see why you were worried. Because this medicine protects you from a different kind of risk, I do not want you to make further changes without the team who knows why it was prescribed.’
• I would give only advice within my role and follow local epistaxis, anticoagulation and escalation guidance.

4 · Coordinate care

• I would arrange ENT assessment and, where needed, involve the anticoagulation, cardiology, haematology or medical team responsible for the indication.
• I would make sure the patient knows which team will tell them about any medicine change and how they will be contacted.

5 · Safety-net and confirm understanding

• I would give clear emergency triggers, including ongoing heavy bleeding, collapse, breathlessness, chest pain, neurological symptoms or inability to control bleeding.
• I would ask the patient to repeat the agreed plan and record the discussion, medication status and named follow-up clinician.

1 · Make urgency explicit

• I would say calmly: ‘Bleeding after this operation needs urgent assessment even if it seems to have slowed. Please arrange emergency help now; I will stay focused on what happens next.’
• I would avoid giving complex home treatment that delays emergency assessment.

2 · Collect only action-critical information

• I would establish the child’s current state, amount and recurrence of blood, consciousness, breathing, vomiting blood, oral intake, time since operation, medical conditions and current location.
• I would confirm an adult is present and that the caller can arrange emergency transport/attendance immediately.

3 · Use closed-loop communication

• I would ask the caller to repeat the immediate plan: where they are going, who is taking the child, and what to do if the child deteriorates while waiting.
• If they are unable to arrange urgent help, I would escalate through the emergency pathway rather than accepting delay.

4 · Prepare the handover

• I would provide operation timing, bleeding description, current observations if known, comorbidity, medication, fasting/intake information and the exact escalation already arranged.
• I would name the concern clearly as possible post-operative haemorrhage and document the time of the call.

5 · Show professional judgement

• I would recognise the limits of remote assessment, seek senior support early and ensure there is no ambiguity about who now owns the child’s urgent care.
• I would not be reassured simply because the bleeding has stopped temporarily.

1 · Establish the clock and current safety

• I would confirm when hearing was last normal and whether the loss developed over three days or less. I would check whether symptoms are still evolving, whether the patient is safe to travel, and whether there is vomiting, inability to mobilise or severe distress.
• I would ask directly about facial weakness or numbness, new diplopia, dysarthria, limb symptoms, severe new headache and an acute vestibular syndrome. These features need urgent senior assessment and an emergency neurological pathway where indicated.

2 · Exclude obvious external and middle-ear causes

• I would perform otoscopy and a focused ear examination, looking for wax, acute infection, perforation, discharge or middle-ear pathology. I would describe these steps as exclusion of common mimics, not as a reason to postpone the urgent referral.
• I would ask about recent infection, trauma, barotrauma, ear surgery, ototoxic exposure and relevant vascular or autoimmune history.

3 · Characterise the audiovestibular syndrome

• I would distinguish true vertigo from imbalance or presyncope, ask about tinnitus and aural fullness, and determine the functional effect on communication, work and safety.
• I would arrange formal audiological assessment according to the local urgent pathway, documenting any bedside findings but not over-interpreting them as definitive.

4 · Escalate on the appropriate pathway

• NICE NG98 recommends immediate referral to ENT or an emergency department for sudden onset hearing loss developing over three days or less within the previous 30 days when it is not explained by external or middle-ear causes. I would activate the local pathway and state who has accepted responsibility.
• I would seek immediate senior input if the neurological screen is concerning, rather than treating this as an isolated ear presentation.

5 · Communicate without delay or alarm

• I would say: ‘Because this change happened quickly, it needs specialist assessment today. There are different possible causes and we should not assume one before the assessment is complete.’
• I would explain the expected route, check transport and communication needs, give a concise safety-net and ensure the patient knows exactly where to go.

6 · Close the loop

• My record would include onset time, otoscopy, neurological screen, functional status, escalation time, receiving team and the exact advice given.
• I would hand over the unresolved questions and avoid recording a confident diagnosis that has not been established.

1 · Take an individualised history

• I would ask about hearing change, nasal obstruction, epistaxis, postnasal symptoms, neck lumps, headache, diplopia, facial altered sensation, weight loss and swallowing symptoms. I would not make assumptions about risk based on heritage alone.
• I would ask what the patient has read, what they are most worried about, whether they would like an interpreter or supporter and how they prefer information to be communicated.

2 · Examine within competence

• I would perform otoscopy and a focused head-and-neck examination, including cranial-nerve screen and neck examination. I would explain that a specialist may need to assess areas not visible through the ear examination.
• I would record the laterality, persistence and any associated findings clearly so that the receiving clinician can make a timely decision.

3 · Explain the differential honestly

• I would explain that a middle-ear effusion can have several causes. In an adult, persistent one-sided disease needs further assessment to avoid missing less common but important explanations.
• I would avoid saying that the referral proves cancer or, conversely, offering reassurance that makes the referral seem unnecessary.

4 · Organise the pathway

• NICE NG98 advises considering suspected-cancer-pathway referral for adults of Chinese or south-east Asian family origin with hearing loss and middle-ear effusion not associated with upper respiratory infection. I would follow the local pathway and senior advice.
• I would confirm who will review any results, the expected contact route and what happens if the patient has not heard within the agreed interval.

5 · Safety-net specifically

• I would give written and verbal escalation advice for new neurological symptoms, progressive nasal bleeding, swallowing or airway problems, rapid clinical deterioration or a new neck lump.
• I would ask for teach-back: ‘Can you tell me what the next appointment is for and what symptoms would make you seek help sooner?’

6 · Demonstrate professional judgement

• I would document the reason for the pathway, the discussion of uncertainty, any communication needs and a named follow-up owner.
• I would ensure the patient has a way to ask questions rather than leaving them with an alarming referral label alone.

1 · Reassess clinical priorities

• I would check airway symptoms, dysphagia, odynophagia, pain, nutrition, weight loss, bleeding, performance status and acute distress. These needs should be addressed alongside—not after—oncological investigation.
• I would establish who is supporting the patient, how much detail they want today and whether a clinical nurse specialist is available.

2 · State what is known and unknown

• I would say: ‘The biopsy tells us that cancer cells are present in this lymph node. We do not yet know where they started or the full stage, and the next tests are designed to answer those questions.’
• I would avoid phrases such as ‘it has spread everywhere’ or ‘we have found the cancer’ when neither statement is justified.

3 · Describe the specialist investigation logic

• I would ensure head-and-neck MDT involvement. NICE NG36 supports FDG PET-CT as the first investigation to detect a primary in metastatic nodal squamous-cell carcinoma of unknown origin thought to arise from the upper aerodigestive tract.
• I would explain that imaging and directed endoscopic assessment/biopsy are complementary. The exact sequence and the interpretation must be determined by the specialist team, not improvised in the station.

4 · Support informed decisions

• Before discussing each test, I would explain its purpose, potential next step and what uncertainty it may or may not resolve. I would pause for questions and avoid overwhelming the patient with jargon.
• I would make sure the patient knows how results will be communicated and who they can contact between appointments.

5 · Hand over to the MDT safely

• I would include pathology, node site, symptom history, airway and nutritional status, comorbidity, communication needs, performance status, scans already done and patient priorities.
• I would document a named clinician/team responsible for actioning results and coordinating the next consultation.

6 · Safety-net

• I would advise urgent reassessment for breathing difficulty, inability to swallow secretions, significant bleeding, rapidly increasing swelling or acute deterioration.
• I would record the discussion of uncertainty and ensure the patient leaves with a clear next contact point.

1 · Decide whether this is an airway emergency

• I would assess for stridor, inability to speak full sentences, increasing work of breathing, cyanosis, inability to swallow secretions, rapidly worsening symptoms and exhaustion. Any concern prompts immediate senior and emergency airway help according to local policy.
• I would not be reassured by a single currently normal observation if the history indicates progression; I would reassess and escalate based on the whole picture.

2 · Build a focused history

• I would clarify duration and progression of voice change, dysphagia, odynophagia, referred otalgia, neck mass, weight loss, haemoptysis, smoking and alcohol history, prior radiation or surgery and comorbidity.
• I would ask about current functional limitation, support at home and the patient’s understanding of the situation.

3 · Explain urgency and pathway

• NICE NG12 advises considering a suspected-cancer-pathway referral for people aged 45 or over with persistent unexplained hoarseness or an unexplained neck lump. In this case, I would arrange urgent ENT/head-and-neck assessment and explain that the pathway is for prompt investigation, not a diagnosis.
• If the airway screen is concerning, I would escalate immediately rather than rely on the outpatient pathway.

4 · Communicate in patient-centred language

• I would say: ‘These symptoms need urgent specialist assessment. Cancer is one possible explanation, but we do not know the cause yet. The important thing is to assess your breathing safely and arrange the right tests quickly.’
• I would pause, allow the patient and partner to respond, offer written information and identify a named contact.

5 · Plan safe transfer and ownership

• I would document airway findings, time course, escalation decision, who accepted referral and the planned destination. I would avoid leaving the patient to organise a complex route unaided if there is a safety concern.
• I would hand over the uncertainty as well as the facts, including any change in symptoms while waiting.

6 · Give an actionable safety-net

• I would define specific triggers: noisy breathing, inability to speak, worsening breathlessness, inability to swallow saliva, collapse or acute bleeding require emergency help.
• I would check understanding with a teach-back question and record it.

1 · Define the symptom accurately

• I would ask the patient to describe whether the sound matches the pulse, whether it is continuous or intermittent, unilateral or bilateral, and what changes it. I would document onset and impact on sleep, concentration, work and wellbeing.
• I would ask about hearing change, vertigo, headache, visual symptoms, neurological symptoms, trauma, pregnancy where relevant, cardiovascular history and medication, avoiding a premature single-cause explanation.

2 · Identify immediate concerns

• I would perform a focused otological and neurological examination within competence, including cranial nerves and assessment for a middle-ear abnormality. I would seek urgent senior input for concerning focal neurological or acute systemic features.
• I would also assess distress and safety, including whether the symptom is causing severe anxiety, sleep loss or functional impairment that needs support alongside investigation.

3 · Use audiology and imaging logically

• I would arrange or confirm audiological assessment and explain that it forms part of a structured evaluation. I would not treat a normal result as proof that no further assessment is needed.
• NICE NG155 recommends imaging for pulsatile tinnitus. For synchronous pulsatile tinnitus with normal clinical and audiological assessment, it advises considering MRA or MRI of head, neck, temporal bone and IAM; the exact modality and pathway should be agreed with the specialist team.

4 · Explain uncertainty well

• I would say: ‘This symptom has a number of possible explanations. The examination today does not tell us the cause, which is why we are arranging the right imaging rather than guessing.’
• I would avoid listing rare diagnoses in a way that amplifies fear, but would be clear that investigation is important and will be actively followed up.

5 · Close with accountable follow-up

• I would document the symptom pattern, examination, audiology plan, imaging route, red-flag screen and named clinician responsible for results.
• I would safety-net for new focal neurological symptoms, severe new headache, visual disturbance, rapidly worsening symptoms or acute functional decline.

1 · Establish acuity and safety

• I would clarify precisely when facial asymmetry and altered sensation began, whether they are progressing and whether there is dysarthria, diplopia, limb weakness, severe headache, new imbalance or inability to walk.
• I would take observations and seek urgent senior/emergency assessment if the presentation suggests an acute neurological process; I would not delay this for detailed outpatient testing.

2 · Complete a focused examination

• I would assess facial movement, eye closure, facial sensation, other cranial nerves, speech, limbs and gait where safe, documenting positive and negative findings precisely.
• I would perform otoscopy and assess hearing history, but would not let a normal ear canal examination falsely reassure me in a localising presentation.

3 · Explain the investigation principle

• NICE NG98 advises immediate referral within 24 hours for acquired unilateral hearing loss with altered sensation or facial droop on the same side, or a local stroke pathway if stroke is suspected.
• NICE also advises MRI of the internal auditory meati for hearing loss with localising signs such as facial nerve weakness; the timing and exact test are led by the accepting service and clinical context.

4 · Communicate urgency precisely

• I would say: ‘The change in your facial movement and sensation means we need specialist assessment urgently. There are different possible causes, so we should not assume the diagnosis before you are assessed.’
• I would check transport, communication needs and whether the patient has a supporter, while making clear that escalation is an active plan rather than a routine referral.

5 · Hand over and safety-net

• My handover would state onset, progression, neurological examination, otoscopy, hearing change, observations, working concern and the action already agreed with the receiving service.
• I would advise emergency reassessment for any worsening facial weakness, new limb or speech symptoms, severe headache, collapse or inability to mobilise.

1 · Identify immediate risk

• I would ask about inability to swallow saliva, acute shortness of breath, choking episodes, fever, wet voice, recurrent chest symptoms, dehydration, reduced urine output and current nutritional intake.
• Any acute respiratory compromise, inability to manage secretions or major deterioration needs urgent senior/emergency assessment rather than a routine rehabilitation plan.

2 · Build the functional picture

• I would clarify which consistencies cause difficulty, coughing during or after meals, pain, fatigue, mouth opening, oral pain, treatment timing, weight trajectory, dentures and the patient’s own goals for eating and drinking.
• I would ask what support is available at home and whether the person understands the current treatment-related effects, without assuming that symptoms are an unavoidable consequence of therapy.

3 · Arrange the right assessment

• NICE CG32 states that people with indicators of dysphagia should be referred to professionals with relevant skills and training in diagnosing, assessing and managing swallowing disorders.
• I would involve speech and language therapy and dietetic/nutrition support through the local head-and-neck MDT, explaining that individual swallow assessment guides safe recommendations.

4 · Communicate boundaries and options

• I would say: ‘I understand you want something practical today. Because swallowing problems are different for each person, the safest step is a specialist assessment before we make personalised food or drink changes.’
• I would address pain, hydration, nutrition and quality-of-life concerns in parallel, with the appropriate team rather than treating aspiration risk as a single-discipline problem.

5 · Create ownership and safety-net

• I would document symptoms, intake, weight concern, respiratory red flags, referrals, named review owner and what advice has actually been given.
• I would safety-net for inability to swallow saliva, acute breathing difficulty, worsening chest symptoms, dehydration or rapid nutritional decline.

1 · Establish clinical urgency

• I would ask about duration, growth, bleeding, pain, dysphagia, odynophagia, voice change, otalgia, weight loss, airway symptoms and the time course of the neck lump.
• I would assess immediate safety and nutritional impact while recognising that a stable appearance does not remove the need for timely specialist assessment.

2 · Examine and describe

• I would perform an oral cavity and neck examination within competence, recording the lesion site, size, surface, induration if assessable, bleeding, tenderness, dental context and nodal findings.
• I would not repeatedly manipulate a painful lesion or attempt a procedure beyond my competence; clear description and appropriate referral are more valuable than false precision.

3 · Explain the referral truthfully

• NICE NG12 advises considering a suspected-cancer pathway for unexplained oral ulceration lasting more than three weeks or a persistent unexplained neck lump. I would explain that the route aims to investigate promptly, not declare a diagnosis.
• I would say: ‘There are several causes. Because it has persisted and there is a neck lump, the safest course is a prompt specialist assessment.’

4 · Work through the attendance barrier

• I would ask what makes the appointment difficult—fear, work, travel, cost, caring responsibilities or previous experiences—and explore practical support, appointment coordination and a supporter where available.
• I would recommend timely assessment clearly while respecting autonomy; I would document the conversation and any decision to defer, with a robust safety-net.

5 · Close the loop

• I would ensure the referral contains the full history, lesion and neck findings, symptom burden, risk context, communication needs and agreed contact details.
• I would safety-net for bleeding, inability to swallow, breathing problems, rapid increase in swelling or systemic deterioration.

1 · Observe before intervening

• I would assess work of breathing, respiratory rate, colour, alertness, ability to vocalise, drooling, posture, hydration and whether stridor is at rest, avoiding unnecessary handling.
• I would keep the child with the parent and avoid upsetting procedures that can worsen respiratory effort while urgent help is being arranged.

2 · Recognise emergency features

• I would identify severe work of breathing, marked recession, cyanosis or pallor, abnormal drowsiness, agitation, inability to swallow or worsening stridor as features needing immediate emergency escalation.
• The NHS advises urgent help for children with croup who struggle to breathe, are unusually sleepy or difficult to wake, have colour change, drooling or difficulty swallowing.

3 · Escalate early and clearly

• I would call senior paediatric and ENT/emergency support according to local policy, state the child’s current appearance and respiratory effort, and ensure airway equipment and an appropriate environment are considered by the experienced team.
• I would not attempt a prolonged throat examination or a procedure outside my competence in a potentially unstable airway.

4 · Speak to the parent

• I would say: ‘Your child’s breathing is working harder, so our priority is to keep them calm and get the senior team here now. Please stay close; you are helping by keeping them settled.’
• I would give brief, repeated information rather than a technical differential, and check that the parent understands where help is coming from.

5 · Document and hand over

• I would record the time course, whether stridor is at rest, observations, work of breathing, hydration, escalation time and accepting clinician.
• I would use a closed-loop handover and continue reassessment while awaiting the senior team, escalating further if the child deteriorates.

1 · Establish understanding and priorities

• Ask what the patient has been told, invite correction, establish capacity and permission for partner involvement.
• Elicit priorities around cure, natural voice, swallowing, work, caring roles, body image and tolerance of uncertainty; acknowledge emotion before adding information.

2 · Explain the recommendation

• Describe removal of the larynx, separation of airway from mouth and throat, a permanent neck stoma and loss of laryngeal voice. Nodal surgery, thyroid resection, flap reconstruction or adjuvant treatment depend on mapped disease and pathology.
• Relate the recommendation to resectable T4a disease and baseline function. Contrast organ-preservation treatment honestly: retaining an organ does not guarantee a safe functioning larynx, and failed treatment may require higher-morbidity salvage.

3 · Make rehabilitation concrete

• Explain primary or secondary tracheoesophageal puncture where suitable, electrolarynx and oesophageal speech; introduce speech and language therapy before surgery.
• Cover permanent stoma care, loss of nasal airflow and altered smell, humidification/pulmonary care, water precautions, emergency communication, early enteral nutrition and later swallow rehabilitation.

4 · Consent and alternatives

• Discuss bleeding, infection, pharyngocutaneous fistula, wound breakdown, dysphagia/stricture, shoulder or nerve morbidity, hypothyroidism/hypocalcaemia where relevant, voice/stoma consequences, flap failure and return to theatre.
• Offer a balanced discussion of non-surgical oncological treatment, second opinion and symptom-focused care according to stage and fitness; do not imply equivalent outcomes when they are not equivalent.

5 · Close with ownership

• Use teach-back, summarise values and unanswered questions, offer peer support if desired and arrange defined review with surgeon, CNS and SLT.
• Document recommendation, alternatives, values and material risks. Escalate airway, aspiration, bleeding or nutritional deterioration while deliberation continues.

1 · Define threat and extent

• Ask about facial weakness, severe vertigo, headache, fever, post-auricular swelling, neurological symptoms and previous surgery. Microscopically examine both ears and document keratin, granulation and limits of view; assess facial nerve, fistula symptoms and mastoid.
• Perform tuning-fork tests and formal audiometry; contralateral hearing materially changes operative risk tolerance.

2 · Image and interpret

• Use high-resolution CT temporal bones when anatomy, complication or operative planning requires it; interpret scutum, ossicles, tegmen, labyrinth, facial canal and mastoid aeration.
• Use non-echo-planar diffusion-weighted MRI for residual/recurrent disease or diagnostic uncertainty; imaging complements examination.

3 · Control active disease

• Use microsuction and topical non-ototoxic treatment for active discharge. Systemic therapy/admission is for spreading or complicated infection, not definitive routine care.
• Facial palsy, labyrinthitis, mastoiditis or intracranial concern triggers urgent admission, imaging, antimicrobial planning and source control.

4 · Choose surgery

• Recommend surgery for a safe dry ear. Canal-wall-up preserves anatomy but requires reliable second-look or diffusion-MRI surveillance; canal-wall-down improves exteriorisation in extensive or poorly surveillable disease but creates cavity-care and water/hearing consequences.
• Describe tympanomastoid clearance, facial/labyrinth/tegmen protection and staged or immediate ossiculoplasty according to residual disease, mucosa and stapes; never prioritise hearing reconstruction over eradication.

5 · Consent and follow through

• Discuss residual/recurrent disease, worse or dead ear, dizziness, tinnitus/taste disturbance, facial weakness, CSF leak, infection, cavity care and revision.
• Own long-term otoscopy, audiology and imaging/second-look, with urgent routes for facial weakness, severe vertigo, systemic illness or neurological symptoms.

6 · State the operation and clearance sequence

• For attic disease extending beyond view, recommend tympanomastoid surgery with the approach determined by endoscopic and microscopic extent, canal-wall erosion, mastoid anatomy, complications and the patient’s ability to attend surveillance. Start by establishing orientation and a safe route to disease, identify the lateral semicircular canal, facial-nerve course, tegmen and sigmoid plate, and clear from known anatomy towards the sac rather than avulsing hidden matrix.
• Use endoscopy as an adjunct to inspect the sinus tympani, facial recess, anterior epitympanum and other recesses, not as proof that inaccessible disease has been cleared. Preserve the posterior canal wall when complete clearance and dependable long-term surveillance are realistic. Choose canal-wall-down exteriorisation, with reconstruction or obliteration where appropriate, when disease is extensive, anatomy is unsafe, the canal wall is destroyed, complications are present or reliable residual-disease surveillance cannot be secured.

7 · Protect labyrinth, facial nerve and dura

• With a suspected lateral semicircular-canal fistula and an only-hearing or best-hearing ear, counsel explicitly about dead ear, vertigo and balance failure. Expose the fistula last under direct vision, avoid suction or mechanical trauma directly over it, control the matrix according to fistula size, epithelial adherence and hearing, and seal the defect promptly if the labyrinth is opened. Facial monitoring is an adjunct; it never substitutes for anatomical identification or gentle dissection over a dehiscent nerve.
• If dura or tegmen is exposed, remove disease without blind traction and inspect for a CSF leak. Repair a leak in a watertight layered fashion with appropriate autologous material and involve skull-base expertise for a large defect, encephalocele or intracranial extension. Facial weakness, profound sensorineural loss, persistent severe vertigo or neurological deterioration after surgery requires urgent examination, audiovestibular assessment and imaging rather than routine outpatient review.

8 · Reconstruct hearing and make surveillance measurable

• Reconstruct hearing only after the safe-ear objective is met. With an intact mobile stapes superstructure, consider a partial ossicular replacement or cartilage-supported reconstruction; with no superstructure but a mobile footplate, a total prosthesis may be considered. Stage ossiculoplasty when mucosa is hostile, clearance is uncertain or a planned second look is required. Explain that an air–bone-gap improvement is an aim, not a guarantee, and compare conventional or bone-conduction hearing rehabilitation if reconstruction is unsuitable.
• Record the operative map, residual-risk sites, reconstruction and whether the canal wall is preserved. Arrange serial otoscopy and audiometry, and non-echo-planar diffusion-weighted MRI or planned second-look surgery according to technique and risk. Surveillance must continue long enough to detect late residual or recurrent disease; a dry ear at the first postoperative visit is not discharge from care.

1 · Clinical staging

• Clarify pain, numbness, trismus, skin/ear-canal change, otalgia, dysphagia and previous cutaneous cancer. Examine fixation, oral cavity, all facial divisions, trigeminal function and every neck level.
• Record facial function reproducibly and protect the cornea immediately if closure is impaired.

2 · Tissue and imaging

• Arrange expert ultrasound of gland/neck with image-guided FNA or core and specialist pathology; avoid open biopsy and capsular violation.
• MRI maps deep-lobe, skull-base and perineural disease; CT stages bone/chest and nodal disease where appropriate.

3 · Primary and facial nerve

• Resect with adequate margins. Preserve a functioning uninvolved nerve where a plane exists; weakness, perineural spread or gross encasement may require segmental sacrifice.
• If sacrifice is expected, plan margins, immediate cable grafting when possible, static/dynamic reanimation and eye protection according to level and prognosis.

4 · Neck, defect and adjuvant care

• Perform therapeutic neck dissection for involved nodes; elective treatment depends on stage, grade and histology. Plan reconstruction for skin, mandible or parapharyngeal extension.
• Consider adjuvant radiotherapy for high grade/stage, close or positive margins, perineural invasion and nodal disease.

5 · Consent and ownership

• Discuss facial weakness, eye morbidity, numbness, Frey syndrome, contour deformity, first-bite pain, salivary leak, shoulder dysfunction, recurrence and adjuvant effects.
• Coordinate pathology-driven review and long surveillance with facial/ophthalmic rehabilitation already activated.

6 · Commit to an oncological operation

• For a resectable high-grade parotid malignancy with clinical level II nodal disease, recommend en-bloc oncological parotid resection and an ipsilateral therapeutic neck dissection covering involved and at-risk levels, commonly II–IV and extended according to nodal distribution, primary histology and access requirements. Review the skin examination and previous cutaneous pathology because an intraparotid metastasis from cutaneous squamous carcinoma changes the search for the primary, resection and adjuvant fields.
• Map deep-lobe and parapharyngeal extension, masseter or mandible involvement, external auditory canal and temporal-bone proximity, skin involvement and perineural spread before theatre. Resect invaded skin, muscle, canal or bone en bloc when required for clearance; do not peel tumour from an involved structure to preserve appearance. If carotid encasement, unreconstructable skull-base spread or distant disease makes curative surgery disproportionate, state that the recommendation changes to a non-surgical or palliative pathway after disease-specific MDT review.

7 · Manage the facial nerve at the stylomastoid foramen

• Record preoperative function branch by branch and counsel that existing weakness makes invasion likely. Preserve functioning branches only where a genuine oncological plane exists. If the main trunk is grossly invaded at the stylomastoid foramen, sacrifice the involved segment with the specimen, obtain proximal and distal margins, and expose a healthy proximal segment in the mastoid facial canal when necessary rather than dividing through suspected perineural disease.
• When viable proximal and distal ends remain, perform immediate tension-free primary repair or interposition cable graft—often using greater auricular or sural nerve—coapting the trunk to prioritised distal divisions. If no usable proximal stump exists, plan immediate nerve transfer, such as masseteric-to-facial reinnervation, with static suspension as required. Document that reinnervation is delayed, incomplete and affected by denervation time and radiotherapy; it does not replace immediate eye protection.

8 · Reconstruct function and rescue complications

• Close the eye-protection gap on the day of surgery: lubrication, taping and ophthalmology/facial-palsy input, with upper-lid loading and lower-lid support selected for exposure and prognosis. Restore facial contour and cover exposed vessels or nerve graft with an appropriate regional or free flap when the defect is large; use static sling or dynamic reanimation according to remaining musculature, prognosis and expected adjuvant treatment.
• After surgery, escalating pain, tense swelling, airway change or brisk drain output requires urgent assessment for neck haematoma and airway compromise. A threatened flap needs immediate perfusion review; progressive corneal exposure needs same-day protection; salivary collection or fistula requires confirmation, drainage when indicated, pressure and infection control rather than repeated blind aspiration. Shoulder rehabilitation, facial therapy, nutrition, pathology review and radiotherapy planning are named follow-up responsibilities, not deferred tasks.

1 · Stabilise

• Assess airway, breathing, oxygenation, air entry, cry and fatigue while keeping the child calm with a parent. Complete obstruction requires age-appropriate choking manoeuvres, not blind sweeps.
• Keep fasted and avoid sedation outside the controlled airway plan.

2 · Decide clinically

• Clarify witness, object, time, cyanosis, transient recovery and current focal signs. Examination may be normal.
• Radiographs may show air trapping, collapse or a radio-opaque object, but normal imaging does not exclude radiolucent material. Strong suspicion warrants bronchoscopy rather than CT-driven delay.

3 · Plan rigid bronchoscopy

• Use an experienced paediatric ENT–anaesthetic team with age-appropriate rigid bronchoscopes, optical forceps, suction and backup airway equipment. Agree ventilation and communication at every airway handover.
• Inspect both bronchi after retrieval for fragments, mucosal injury and a second object; nuts fragment and swell.

4 · Rescue difficulty

• If saturation falls or the object migrates, pause attempts, oxygenate and use the agreed retrieval/airway plan. Escalate operator/equipment and involve cardiothoracic support exceptionally.
• Antibiotics do not substitute for source removal.

5 · Aftercare

• Observe for stridor, bronchospasm, pneumothorax, bleeding, hypoxia and persistent focal signs.
• Explain completeness and return precautions; provide prevention advice without blame.

6 · Agree the anaesthetic–surgical operating plan

• Brief spontaneous versus controlled ventilation as a joint decision based on location, obstruction, operator preference and the child's physiology; neither technique is a slogan. Confirm rigid scope sizes, telescope, optical and non-optical forceps, suction, retrieval basket and a second set for breakage before induction.
• Agree who controls the airway at each moment, when ventilation pauses for extraction and the signal for abandoning repeated attempts to re-oxygenate. If the object cannot pass the subglottis safely, do not force it and convert to the planned alternative retrieval strategy.

7 · Manage distal migration and incomplete clearance

• If the nut fragments, withdraw to oxygenate, re-localise systematically and remove pieces under direct vision. Inspect the contralateral bronchial tree and the original site, but stop if swelling, bleeding or physiological instability makes further instrumentation more dangerous than staged re-look.
• Persistent focal signs after an apparently complete procedure require repeat clinical and imaging assessment and possible repeat bronchoscopy. Discharge requires stable breathing, an agreed observation period and precise return advice for stridor, increased work, fever or recurrent focal symptoms.

1 · Trauma threats

• Use ABCDE, GCS trend, focal neurology, pupils/vision/movements, facial fractures and raised-pressure signs. Involve neurosurgery and relevant trauma teams.
• Avoid nasogastric/nasotracheal instrumentation, forceful nose blowing and provocative testing.

2 · Confirm/localise

• Send fluid for beta-2 transferrin or beta-trace protein; glucose testing is unreliable.
• Review thin-slice CT; use high-resolution CT and MR cisternography when required. Reserve intrathecal localisation for selected difficult cases.

3 · Initial care

• Observe according to head injury and leak features, elevate head and avoid straining. Routine prophylactic antibiotics are not automatic; investigate and treat suspected meningitis promptly.
• Do not use lumbar drainage reflexively with mass effect, obstructive hydrocephalus or unassessed pressure.

4 · Select repair

• Persistent leak, large defect, encephalocele, recurrent meningitis, significant pneumocephalus or failed conservative care supports repair.
• Plan endoscopic multilayer closure with graft/flap matched to site and flow; open/combined access is for anatomy, associated injury or failed endoscopic control.

5 · Consent/follow-up

• Discuss bleeding, meningitis, anosmia, intracranial/visual/vascular injury, recurrence and need for open repair.
• Monitor neurological state and give urgent routes for fever, neck stiffness, photophobia, confusion or recurrent leak.

6 · Build a defect-specific reconstruction

• Review the defect site, size, flow, comminution, encephalocele and intracranial pressure context with skull-base rhinology and neurosurgery. Low-flow focal defects may accept layered free grafts, while larger or high-flow defects usually need a vascularised flap and secure separation of the cranial and sinonasal compartments.
• Prepare graft and flap alternatives, image guidance and a route for vascular or orbital injury. If landmarks are destroyed, active intracranial bleeding is suspected or a safe endoscopic seal cannot be demonstrated, stop and convert to the agreed combined or open strategy rather than persisting blindly.

7 · Test the repair and own recurrence

• Use selective localisation adjuncts only when their benefit justifies risk. Lumbar drainage is not routine and must be considered against mass effect, hydrocephalus, pneumocephalus and the possibility of worsening intracranial air ingress.
• After repair, define neurological and leak observations, precautions, meningitis education and the route for recurrent clear rhinorrhoea. A recurrent leak triggers re-localisation and review of closure failure or raised pressure—not repeated empirical antibiotics.

1 · Define person and problem

• Clarify obstruction, prior records/grafts, healing, smoking and the unacceptable outcome. Explore preoccupation, impairment, prior dissatisfaction and BDD features without stigma.
• Use standardised photographs and external/internal dynamic assessment: skin, scars, vault, tip, septum, turbinates and valves.

2 · Planning information

• Retrieve notes/photos. Endoscopy assesses septum, valve, perforation and other obstruction; CT is not routine without sinus disease/trauma.
• Allow tissue maturation, commonly about 12 months unless urgent structural need dictates otherwise.

3 · Reconstruct

• Explain open revision, scar release and support restoration. Spreader graft/autospreader supports internal valve/middle vault; alar batten or lateral-crural reconstruction addresses wall collapse.
• With depleted septum, discuss auricular versus costal cartilage, including warping, calcification, scar, donor pain and pneumothorax risk.

4 · Consent/boundaries

• Discuss persistent/worse obstruction, asymmetry, contour visibility, graft warping/resorption, infection, bleeding, perforation, skin compromise, smell/sensation change and further revision.
• The operating surgeon obtains consent with reflection. Decline surgery when goals are unattainable or psychological harm likely; a signature does not make harm appropriate.

5 · Agree outcomes

• Document functional and aesthetic goals and the conflict between requested narrowing and required support.
• Offer another opinion and a second consultation rather than booking under pressure.

6 · State the operation and anatomical targets

• My recommendation is delayed open functional revision septorhinoplasty after records, photographs and tissue maturation confirm a stable deformity. Through an external approach I would release scar cautiously, expose the upper lateral cartilages and define whether the obstruction is fixed narrowing, dynamic lateral-wall collapse or both. I would preserve the soft-tissue envelope and blood supply because a scarred thin envelope tolerates repeated dissection poorly.
• Rebuild the pinched middle vault with bilateral spreader grafts or an equivalent autospreader reconstruction, restoring the dorsal aesthetic lines and internal-valve cross-sectional area rather than promising a particular valve angle. Add an alar batten or lateral-crural strut only if sidewall or external-valve weakness persists. Correct residual septal deviation and turbinate disease when genuinely contributory; avoid reflex turbinate reduction as a substitute for valve repair.

7 · Choose graft source and plan the difficult revision

• Use remaining straight septal cartilage first if adequate. Auricular cartilage is useful for curved, lower-force contour or alar support but is limited in volume and rigidity. For major dorsal or caudal reconstruction with depleted septum, recommend autologous costal cartilage, discussing carving, balanced cross-sectional cuts and rigid fixation to reduce—but not eliminate—warping and displacement.
• Before rib harvest, examine the chest, consider previous surgery and imaging only when clinically indicated, and agree the donor site and scar. Consent includes pain, contour deformity, hypertrophic scar, pleural injury and pneumothorax. Cadaveric or other graft materials may avoid donor morbidity but introduce different availability, resorption, infection and evidence uncertainties; the choice must be explicit rather than hidden inside a generic ‘grafting’ consent.

8 · Consent, stopping rules and postoperative rescue

• Separate the functional goal—stable nasal airflow—from aesthetic preferences and document the compromises. Explain oedema and the long time to a stable result, possible persistent or worsened obstruction, asymmetry, visible or palpable graft, warping, infection, bleeding, septal perforation, numbness, altered smell, skin necrosis, donor-site harm and further revision. The operating surgeon leads this discussion, supplies written information and allows reflection; edited photographs are communication aids, not promised outcomes.
• Do not operate when the requested narrowing predictably conflicts with airway reconstruction, expectations remain unattainable, consent is pressured or body-dysmorphic symptoms make harm more likely. Offer time, psychological assessment where indicated and a second opinion. After surgery, expanding septal haematoma, worsening pain, fever, skin colour change or visual symptoms requires urgent assessment; evacuate a septal haematoma, treat infection promptly and remove threatened or infected graft material when salvage is unsafe.

1 · Confirm syndrome

• Document duration/frequency, auditory fluctuation, migraine/positional/neurological features, falls, recovery, driving and work.
• Examine ears, cranial nerves, eye movements, cerebellum and gait. Do not use HINTS indiscriminately between attacks.

2 · Test/mimics

• Repeat audiometry, speech testing and tympanometry. Consider MRI internal auditory meati for asymmetric SNHL/unilateral tinnitus.
• Consider vestibular migraine, BPPV, autoimmune inner-ear disease, canal dehiscence, schwannoma and posterior circulation disease.

3 · Initial management

• Provide a short-term acute suppressant/antiemetic plan where appropriate, avoiding chronic suppression. Discuss sleep, hydration and observed triggers rather than punitive restriction.
• Address tinnitus, hearing aids, falls, occupation and driving; use an attack diary and patient-valued outcomes.

4 · Escalation

• For disabling refractory attacks, compare intratympanic steroid as hearing-preserving but variably effective with gentamicin as stronger vestibular ablation carrying hearing/chronic imbalance risk.
• Labyrinthectomy sacrifices hearing; vestibular nerve section and other surgery require expert selection and contralateral reserve assessment.

5 · Safety

• Persistent focal neurology, severe headache, inability to stand or acute continuous syndrome needs urgent stroke assessment; sudden hearing loss needs urgent assessment.
• Reassess the diagnosis if the pattern changes rather than escalating automatically.

6 · Make the intervention decision

• Confirm that symptoms remain active despite an agreed non-invasive plan and that the diagnosis still fits before offering an intratympanic treatment. With useful hearing and disabling attacks, offer intratympanic steroid as the hearing-preserving procedural step, explaining that vertigo control is not guaranteed. If attacks remain disabling after non-ablative treatment, discuss titrated intratympanic gentamicin as vestibular ablation rather than presenting it as a routine injection.
• Before gentamicin, document ear-specific pure-tone and speech hearing, vestibular function, gait and contralateral auditory/vestibular reserve. Agree the treatment endpoint and review interval. Stop further dosing when adequate vertigo control, new hearing deterioration or excessive disequilibrium occurs; do not continue automatically to a fixed course without reassessment.

7 · Select surgery, consent and rehabilitation

• For persistent disabling unilateral disease with non-serviceable hearing after less definitive treatment, labyrinthectomy is the clearest destructive surgical option, with explicit consent that residual hearing will be lost. When useful hearing remains, vestibular nerve section is a highly selected hearing-preserving ablative operation whose intracranial risks, CSF leak risk, postoperative imbalance and uncertain hearing preservation must be weighed against continued attacks. Do not offer either operation until the side and diagnosis are secure.
• Explain that every ablative option trades episodic vertigo for an acute unilateral vestibular loss that requires central compensation. Arrange vestibular rehabilitation for chronic imbalance, falls or incomplete compensation; continue hearing rehabilitation and tinnitus support. Review serial audiometry and symptoms because future contralateral disease would materially change the original risk calculation.

8 · Own the atypical or failed pathway

• A new continuous acute vestibular syndrome, inability to stand, severe occipital headache, diplopia, dysarthria, limb ataxia or other focal neurology is not a Ménière’s escalation problem: activate an urgent posterior-circulation stroke pathway. A sudden sustained hearing drop also needs urgent sudden-sensorineural-hearing-loss assessment rather than waiting for a routine Ménière’s review.
• If the patient remains symptomatic after a technically adequate treatment, revisit the diagnosis, attack phenotype, treatment adherence and objective hearing before escalating. Do not destroy the second ear, repeat gentamicin reflexively or attribute persistent unsteadiness to active hydrops without separating recurrent attacks from uncompensated vestibular loss, vestibular migraine and central disease.

1 · Triage

• Assess stridor, secretion handling, pneumonia, hydration, nutrition and weak cough. Stridor suggests competing pathology or bilateral dysfunction and demands urgent reassessment.
• Use SLT-led FEES or videofluoroscopy. Individualise texture/strategy and enteral support; do not prescribe blanket thickening.

2 · Confirm mechanism

• Review surgery, monitoring events, pre-operative voice/laryngoscopy, histology and onset. Document position, tone, compensation, pooling and airway; stroboscopy assesses vibration.
• Laryngeal EMG after an appropriate interval can inform prognosis; image the vagal/RLN course if surgery does not adequately explain it.

3 · Early rehabilitation

• Begin voice therapy and airway-protection strategies. For aspiration, weak cough or disabling dysphonia, offer temporary injection laryngoplasty with resorbable material while recovery remains possible.
• Explain that early closure can improve rehabilitation without committing to a permanent framework procedure.

4 · Definitive choices

• If recovery is unlikely/persistent, compare type I thyroplasty, longer-lasting injection and selected reinnervation; arytenoid adduction may address posterior gap/height mismatch.
• Consent includes airway compromise, displacement/extrusion, infection, over/under-correction, persistent symptoms and revision.

5 · Ownership

• Treat pulmonary/nutritional consequences and communicate openly without premature attribution.
• Set dates for laryngoscopy, voice/swallow outcomes and decision review; give urgent routes for breathing difficulty or chest infection.

6 · Convert laryngoscopy into a procedural choice

• Describe the resting fold position, phonatory gap, vocal-process height, bowing, compensation, secretion pooling and mucosal wave. A small anterior or spindle gap may respond to injection alone; a substantial posterior gap or vertical-level mismatch makes arytenoid repositioning more relevant, while poor pulmonary reserve and aspiration increase the value of prompt closure.
• For temporary injection, choose awake office treatment or general anaesthesia according to airway safety, tolerance, anatomy and the need for precision. Place material deeply and laterally to medialise the thyroarytenoid complex; avoid superficial injection that disrupts the mucosal wave. Select a resorbable material while recovery remains possible and document the intended duration and review point.

7 · Plan definitive surgery and rescue failure

• If recovery is improbable and disability persists, recommend framework surgery when a durable, adjustable correction is needed. Size the type I thyroplasty implant to close the membranous gap without over-medialisation; add arytenoid adduction selectively for posterior gap or height mismatch rather than routinely. Reinnervation may improve tone in selected patients but does not provide immediate closure and therefore cannot solve current aspiration alone.
• After injection or framework surgery, reassess airway, voice and swallow. New stridor, rapidly worsening dyspnoea or an over-tight voice raises over-medialisation, oedema or haematoma and requires urgent laryngeal assessment with airway support and reversal or implant adjustment when necessary. Persistent aspiration triggers renewed FEES/videofluoroscopy, chest and nutritional review, and a decision about repeat or alternative medialisation.

Open and establish priorities

• Check current airway, swallowing, nutrition and communication needs, then ask what matters most to the person and their partner.

Explain the decision

• Describe that more than one treatment approach may be discussed by the specialist MDT, and that the aim is to balance tumour control with voice, swallow and airway consequences.

Avoid false certainty

• State clearly that larynx-preserving treatment does not guarantee normal long-term function and that primary surgery may be discussed where airway or swallow function is already compromised.

Support a valid choice

• Invite questions, offer specialist nurse and speech-and-language support, and allow time to consider information rather than seeking an immediate decision.

Close safely

• Name the MDT route, document the patient’s priorities and safety-net for breathing, aspiration, intake or pain deterioration.

Set the frame

• Clarify the confirmed diagnosis, stage information already available, symptoms, nutritional status, dentition and the person’s goals.

Explain the neck issue

• Explain that the absence of palpable nodes does not by itself finish assessment of the neck and that the specialist team considers neck management as part of definitive planning.

Coordinate MDT decisions

• Describe appropriate imaging, pathology review, surgical and reconstructive assessment and specialist nurse/dietetic input without naming an individualised operation prematurely.

Discuss options proportionately

• Explain that the MDT may discuss surgical neck management and, for some eligible people, sentinel-node biopsy; discuss benefits, uncertainties and functional consequences in plain language.

Document and support

• Record priorities, support needs and the agreed next step, with a named team responsible for results and safety-netting.

Recognise and stabilise

• Review observations, drain volume and timing, wound/neck appearance, respiratory status, oral intake and overall clinical condition.

Clarify the operative context

• Establish the procedure, side, level of surgery, drain history and when the character of output changed.

Escalate early

• Seek the operating team or senior head-and-neck review promptly; describe the finding, output trend and current stability clearly.

Protect the patient

• Do not independently remove the drain or improvise diet or procedural management; follow the specialist plan and involve nutrition support where directed.

Explain and document

• Explain that the drain finding needs specialist assessment, record the volume/character and name the accepting clinician and plan.

Start with trauma priorities

• Confirm airway, breathing, circulation, consciousness, cervical-spine precautions and current trauma-team involvement before an ENT-focused examination.

Screen for time-critical signs

• Clarify onset/progression of facial symptoms, hearing and vestibular symptoms, neurological signs, visual symptoms and any clear fluid leakage.

Assess within competence

• Describe external ear/cranial-nerve assessment and careful otoscopy only when safe; avoid unnecessary manipulation in an unstable trauma context.

Coordinate escalation

• Communicate with trauma, emergency, radiology and senior ENT teams through local pathways; distinguish assessment from definitive treatment decisions.

Document and safety-net

• Record baselines, serial change, neurological findings, imaging plan and named responsibility for reassessment.

6 · Establish the baselines that determine later treatment

• Ask the trauma team, witnesses and paramedics whether facial movement was seen immediately after injury; if intubation or sedation makes onset unknowable, state that explicitly rather than calling the palsy delayed. Grade each facial region with House–Brackmann, record eye closure and corneal protection, and use consented photographs or video for serial comparison. Examine the remaining cranial nerves, pupils, ocular movements and cerebellar signs once safe.
• Inspect the pinna and canal gently for laceration, step deformity, haemotympanum, tympanic-membrane perforation or clear fluid. Do not irrigate, microsuction deeply or repeatedly instrument a bleeding canal. Perform bedside Weber and Rinne if cooperation permits, document vertigo and spontaneous or gaze-evoked nystagmus, and arrange formal pure-tone and speech audiometry when physiologically stable.
• Start corneal protection immediately when closure is weak: frequent preservative-free lubrication, ointment and eyelid taping or moisture chamber, with urgent ophthalmic review for exposure, reduced corneal sensation or epithelial injury. Facial-nerve diagnostics must never delay eye protection.

7 · Use imaging to answer a defined question

• Follow the head-injury pathway: ear bleeding, haemotympanum, CSF leakage or a focal neurological deficit are signs that may mandate urgent CT head. Review the trauma CT for intracranial haemorrhage, pneumocephalus and an otic-capsule–sparing or –disrupting fracture, but request thin-section high-resolution temporal-bone CT when facial paralysis, CSF leak, suspected ossicular or otic-capsule injury, or operative planning requires greater definition.
• Trace the facial canal for a displaced fracture, bony spicule or discontinuity; assess tegmen, labyrinth, ossicles, carotid canal, jugular foramen and external canal. A fracture involving or closely threatening the carotid canal, expanding neck haematoma or compatible neurological deficit requires CT angiography and neurovascular discussion—never blind canal exploration.

8 · Make the facial-nerve decision rather than merely escalating

• Delayed-onset or incomplete weakness usually represents oedema with an intact nerve. Unless contraindicated, I would use a defined corticosteroid course under the skull-base pathway, continue eye care and document serial recovery. Immediate complete paralysis is different: obtain high-resolution CT and arrange serial electrodiagnostics after Wallerian degeneration has had time to occur; electroneuronography is most informative from about day 3 and within the first 2 weeks, with electromyography adding evidence of denervation or recovery later.
• Marked degeneration on serial testing—often described as greater than 90%—is a poor-prognosis signal, not an automatic operation. I would recommend exploration when an immediate complete palsy is supported by severe electrodiagnostic degeneration and CT evidence of focal compression, impalement or discontinuity, or when a surgically repairable transection is suspected. Timing and benefit remain evidence-limited, so the record must show the onset, test timing, imaging target, viable alternatives and the reason surgery is proportionate.

9 · Plan decompression, repair and bailout around anatomy and hearing

• Choose exposure from the injured segment and residual hearing. A transmastoid route can expose the mastoid and tympanic segments and selected geniculate lesions; a middle-cranial-fossa or combined hearing-preserving route may be required for labyrinthine or geniculate disease with serviceable hearing. A translabyrinthine route is reserved for a non-serviceable ear when proximal access justifies sacrificing residual labyrinthine function.
• Decompress the demonstrably injured segment with proximal and distal control rather than unroofing indiscriminately. If the nerve is divided, perform a tension-free primary repair where possible or an interposition graft when a gap remains. Counsel that decompression cannot guarantee normal movement and may cause further hearing loss, vertigo, CSF leak, meningitis, taste disturbance, synkinesis, wound complications or intracranial injury. If anatomy is unsafe, bleeding obscures landmarks or monitoring deteriorates, stop, control the complication, re-image or stage the reconstruction rather than pursuing a hazardous endpoint.

10 · Treat CSF leakage and hearing loss as active pathways

• Send clear fluid for beta-2 transferrin or beta-trace protein when the diagnosis is uncertain, but do not delay neurosurgical/skull-base discussion for a clinically convincing leak. Use head elevation, avoidance of nose blowing, straining and Valsalva, stool softening and close observation for fever, headache, photophobia, neck stiffness or neurological decline. Most traumatic lateral skull-base leaks close conservatively; persistent leakage after roughly 7–10 days, encephalocele, a large non-healing defect, recurrent meningitis or another operative indication supports targeted repair. Routine prophylactic antibiotics remain controversial and should not be presented as a substitute for surveillance and closure of a persistent fistula.
• Reassess hearing after haemotympanum and oedema settle. Persistent conductive loss suggests tympanic-membrane or ossicular injury and may justify delayed tympanotomy and ossiculoplasty after audiology and imaging; profound sensorineural loss implies otic-capsule or cochleovestibular injury and needs rehabilitation planning, including hearing devices or implant assessment as appropriate. Arrange long-term review for canal stenosis, cholesteatoma, vestibular disability, facial recovery and hearing rehabilitation.

Clarify the problem and goals

• Confirm functional impact, hearing history, symptoms, occupational needs, expectations and what a successful outcome means to the person.

Explain assessment

• Describe the role of full otological assessment and audiology in confirming suitability and planning; do not imply suitability from a brief description alone.

Compare options

• Discuss that hearing rehabilitation may include observation, hearing aids and surgery, with the final choice depending on individual findings and priorities.

Make uncertainty explicit

• Explain that surgery has potential benefits and material risks, including the possibility of limited benefit or complications; no normal-hearing guarantee can be made.

Support consent

• Offer written information, a reflection period and a named route for further questions; document values and the discussion.

Recognise urgency

• Treat systemic unwellness, immunocompromise, rapidly progressive pain and concerning nasal findings as requiring immediate senior assessment.

Assess stability

• Review observations, sepsis features, consciousness, visual symptoms, cranial-nerve signs, glucose/medical context and current oncology or haematology input.

Avoid delay

• Do not spend prolonged time attempting a complete clinic examination or making a definitive label before escalation.

Coordinate care

• Contact senior ENT, the responsible medical/haematology team and relevant emergency services through local urgent pathways; communicate concern and time course.

Document and communicate

• Record the exact findings, red flags, time of escalation and accepting clinician; explain to the patient that urgent specialist assessment is needed.

Assess from first contact

• Observe appearance, work of breathing, consciousness, fever and hydration, and seek a focused visual/eye-movement history without forcing examination.

Recognise red flags

• Painful or restricted eye movement, reduced vision, severe swelling, systemic illness or inability to assess the eye require urgent senior escalation.

Coordinate urgent review

• Contact senior ENT, paediatric and ophthalmology teams through local pathways, with emergency support where clinically indicated.

Minimise distress

• Keep the child with their parent, use calm age-appropriate language and avoid prolonged or upsetting examination before senior review.

Close the loop

• Document onset, eye symptoms, observations and escalation; tell the parent exactly what is happening and why urgent assessment is needed.

Call for help early

• Recognise respiratory deterioration in a child with a tracheostomy as an emergency and activate the local emergency response immediately.

Use a safe team approach

• Keep the caregiver present where helpful, bring the child’s emergency equipment and follow the local tracheostomy emergency pathway with senior staff.

Assess without delay

• Observe work of breathing, colour, consciousness, oxygenation, tube history and what has changed; avoid repeated unstructured attempts that delay escalation.

Communicate closed loop

• Assign tasks, repeat key information, confirm who is leading and communicate with paediatric/airway teams using the child’s baseline and current change.

Document and debrief

• Record the event, actions, response and follow-up plan; ensure family communication and post-event review.

1 · Recognise and stabilise

• Check observations, sepsis features, hydration, pain severity, glycaemic control and the patient’s ability to eat, drink and manage at home.
• Treat new facial weakness as a marker of complicated disease and document its onset and progression.

2 · Define local and neurological extent

• Examine the pinna, canal and mastoid region carefully; document granulation, discharge and swelling without traumatic instrumentation.
• Perform and record a complete cranial-nerve examination, including eye closure, swallowing and voice, rather than examining only the facial nerve.

3 · Obtain useful evidence

• Arrange senior-directed microbiology sampling and blood tests including inflammatory markers and renal function; review diabetes control.
• Discuss CT and/or MRI with the named otologist and radiologist to assess soft tissue, bone, skull base and intracranial or vascular complications.

4 · Coordinate treatment safely

• Escalate urgently to senior ENT and involve microbiology/infection specialists; antimicrobial choice and duration must follow cultures, imaging, allergies, renal function and local policy.
• Explain that prolonged treatment and serial clinical, biochemical and sometimes imaging review may be needed; do not promise a rapid outpatient cure.

5 · Communicate and close the loop

• Tell the patient this is a serious but treatable infection requiring hospital specialist care, while avoiding the outdated word ‘malignant’ as though it means cancer.
• Document the accepting clinician, transfer plan, baseline neurology and triggers for further escalation, including worsening weakness, swallowing change, severe headache or confusion.

1 · Start with the person, not the audiogram

• Clarify communication needs, occupation, listening environments, tinnitus, balance, support, previous hearing-aid use and preferred communication methods.
• Ask what the person hopes will change and identify expectations that need careful recalibration.

2 · Explain assessment

• Describe multidisciplinary audiological, medical and functional assessment, including verification that hearing aids have been optimised and consideration of factors affecting benefit and safety.
• Explain that imaging and other investigations are selected by the implant team; candidacy cannot be confirmed from one number or this consultation alone.

3 · Compare reasonable options

• Discuss continued optimised acoustic hearing support, assistive technology and communication strategies alongside implantation where eligible.
• Make clear that choosing assessment does not commit the person to surgery and that declining implantation does not end access to hearing support.

4 · Support valid consent

• Explain surgery, device dependence, variable sound quality and outcomes, possible complications and the need for activation, repeated programming and rehabilitation.
• Discuss the person-specific material issues—work, driving, imaging, device maintenance, communication at home and what happens if benefit is less than hoped.

5 · Close with an accessible plan

• Use teach-back and offer information in the person’s preferred accessible format, with an interpreter or communication professional where needed.
• Document goals, questions, agreed referrals and the named implant-team route for further counselling.

1 · Establish what the result means to the patient

• Ask what they have been told, what they fear about the diagnosis and whether they want their partner included throughout.
• Address airway, swallow, pain, nutrition and communication needs before a long biological explanation.

2 · Explain the test precisely

• Describe p16 as a tumour marker used in oropharyngeal squamous-cell carcinoma and explain that additional high-risk HPV testing may be considered to confirm status.
• Avoid implying recent infection, infidelity or a way to identify the source; use neutral language and allow questions about intimacy and family.

3 · Put prognosis in context

• Explain that HPV status contributes to the clinical picture but individual outlook depends on stage, health, treatment and other factors.
• Do not quote a personalised survival figure or use ‘good cancer’; acknowledge uncertainty and arrange the appropriate oncology discussion.

4 · Frame treatment safely

• State that treatment is based on complete staging, function, comorbidity and MDT review, with patient priorities included.
• NICE advises against de-intensifying curative treatment for HPV-positive oropharyngeal cancer outside a clinical trial; do not present reduced treatment as automatic.

5 · Support and follow through

• Offer specialist nurse, speech-and-language, dietetic and psychosocial support and provide reliable written information.
• Summarise what is known, what remains to be confirmed and who will contact the patient after MDT review; safety-net deterioration in breathing, swallowing, bleeding or intake.

1 · Declare the risk and call for help

• Activate the local major-haemorrhage and difficult-airway response appropriate to the setting and request senior ENT/head-and-neck, anaesthetic and emergency support.
• State explicitly that the bleed has stopped but may be a sentinel event; allocate roles and prepare for rapid change.

2 · Assess with minimal disruption

• Use an ABC approach, obtain observations and appropriate vascular access and blood sampling while avoiding unnecessary wound manipulation.
• Use simple external pressure only if needed and safe while definitive decisions are made; do not blindly explore, clamp or pack a complex irradiated wound.

3 · Clarify treatment context in parallel

• Find the oncology history, imaging, prior procedures, anticoagulants and documented escalation or resuscitation plan without delaying immediate care.
• Determine whether the goal is emergency intervention, symptom-focused care or an agreed middle course, with the responsible senior clinician.

4 · Coordinate definitive or comfort-focused care

• If active intervention is appropriate, senior teams coordinate airway strategy, imaging/interventional radiology or surgery according to stability and local capability.
• If a catastrophic terminal bleed is anticipated under an agreed palliative plan, ensure prescribed crisis medication and staff/family preparation follow local policy; do not abandon the patient.

5 · Communicate and document

• Tell the patient: ‘The bleeding has stopped, but it may recur and could be serious. We are bringing the senior teams now and will stay with you while we agree the safest plan.’
• Record timing, estimated loss, interventions, escalation calls, goals-of-care evidence, who leads and what will happen if bleeding recurs.

1 · Assess immediate safety

• Establish whether bleeding is active, quantify its severity, check haemodynamic symptoms and use an ABC approach when needed.
• Ask about airway symptoms, anaemia, visual change, facial numbness, headache, trismus and neurological symptoms that suggest extension.

2 · Build the focused history

• Clarify duration, laterality, frequency and volume of epistaxis, nasal discharge, smell, hearing symptoms and previous treatment.
• Include medicines, bleeding history and the effect on school, sleep and family, while involving the young person directly and respecting privacy.

3 · Examine without provoking harm

• Perform a gentle external and anterior nasal assessment within competence and document the suspected posterior vascular mass.
• Do not undertake routine office biopsy or traumatic manipulation before imaging and senior skull-base planning because uncontrolled bleeding may result.

4 · Stage through the specialist pathway

• Arrange urgent senior rhinology/skull-base review and appropriate contrast imaging selected by the MDT to define site, vascularity and extension.
• Explain that diagnosis and treatment planning may involve radiology, interventional radiology, anaesthesia and surgery; do not promise a single technique before staging.

5 · Explain and safety-net

• Say: ‘There are several possible causes. Because it may have a rich blood supply, the safest next step is specialist imaging rather than taking a sample today.’
• Provide a specific plan for recurrent heavy bleeding, faintness, breathing difficulty or visual/neurological change and document who will communicate results.

1 · Confirm pattern and screen emergencies

• Clarify onset, progression and associated speech, limb, severe headache or gait symptoms; use the appropriate stroke pathway if central features are suspected.
• Document forehead movement, eye closure and lower-face function, but assess all cranial nerves, cerebellar signs and limbs rather than using forehead involvement as the only test.

2 · Identify the otological syndrome

• Ask about severe otalgia, rash, hearing loss, tinnitus, vertigo and taste change; examine the ear canal, palate and pinna for vesicles.
• Examine the tympanic membrane and parotid/neck and consider infection, cholesteatoma, tumour, trauma and other neurological or systemic causes.

3 · Protect the eye now

• Assess whether the cornea is exposed and whether there is pain, redness or visual change.
• Start local-policy eye lubrication and night closure protection and obtain urgent ophthalmology advice when corneal protection is inadequate or ocular symptoms are present.

4 · Arrange time-sensitive specialist management

• Discuss same-day with senior ENT because vesicles, severe pain and hearing or vestibular symptoms point away from simple idiopathic palsy.
• Antiviral and corticosteroid decisions require prompt patient-specific review of timing, contraindications, pregnancy, diabetes and local guidance; do not delay escalation while debating a memorised dose.

5 · Measure, explain and follow up

• Record a reproducible facial-nerve grade, hearing/vestibular symptoms, eye closure and photographs only with valid consent and governance.
• Explain uncertainty and expected follow-up, and safety-net eye pain/visual change, new neurological symptoms, worsening vertigo, dehydration or progressive weakness.

1 · State the emergency

• Confirm that a button or coin battery may be missing, the possible time, battery/device type and whether choking, drooling, vomiting, pain, cough or breathing change has occurred.
• Do not delay emergency assessment to search the home extensively or wait for symptoms.

2 · Give safe immediate instructions

• Arrange immediate transfer to the nearest appropriate emergency department or ambulance response according to current status and local pathway.
• Advise the parent not to induce vomiting and not to give food or drink while following the emergency team’s instructions; bring the packaging or matching device if immediately available.

3 · Prepare the receiving team

• Provide age, possible ingestion time, symptoms, battery/device details, relevant history and estimated arrival, clearly stating ‘suspected button battery’.
• Notify paediatric emergency, ENT and other required specialists through the local pathway so imaging and removal planning are not delayed.

4 · Explain continuing risk

• Explain that severe oesophageal injury and major bleeding may occur even with limited early symptoms and that removal may not end the need for expert monitoring.
• Avoid giving procedural promises; imaging and specialist assessment determine location and next actions.

5 · Close the loop

• Ask the parent to repeat the destination and immediate action and confirm that transport is underway before ending the call.
• Document exact words, times, symptoms, advice, escalation contacts and who accepted the handover.

1 · Hear the child and family goals

• Ask the child directly using their communication system where possible, and clarify whether the priority is skin comfort, communication, participation, feeding, sleep or respiratory health.
• Explore the burden on family and school without framing the child as a problem to be fixed.

2 · Assess safety and function

• Take a history of coughing, choking, colour or breathing change during meals, meal duration, textures, hydration, growth, chest infections and distress.
• Review posture, reflux, dentition, current medicines and oral care because each can affect drooling and feeding.

3 · Use the multidisciplinary pathway

• Arrange clinical assessment by a speech-and-language therapist trained in dysphagia, including observation during a normal meal, and refer to a specialist MDT when concerning features are present.
• Involve dietetics, paediatrics/respiratory teams, therapists, school and ENT according to need; instrumental assessment follows specialist judgment rather than being automatic first-line testing.

4 · Explain treatment sequencing

• Develop individualised positioning, pacing, texture, equipment, communication and environmental strategies with the family and carers.
• If saliva-control treatment is considered, review benefits, adverse effects and licensed status with the specialist team; surgical options require prior confirmation of swallow safety and consideration of less invasive measures.

5 · Agree outcomes and safety-net

• Choose outcomes that matter to the child and family and schedule review of respiratory events, nutrition, participation and treatment adverse effects.
• Safety-net increased work of breathing, inability to manage secretions, dehydration, marked reduction in intake or acute neurological/respiratory deterioration.

1 · Confirm the clinical baseline

• Clarify hearing trajectory, tinnitus, imbalance, falls, facial sensation or weakness, headache, visual symptoms and functional impact; document a complete cranial-nerve and cerebellar baseline.
• Review audiometry, MRI site and size, internal-auditory-canal/CPA extent, mass effect and any previous imaging rather than counselling from the word ‘small’ alone.

2 · Explain the diagnosis accurately

• Describe a vestibular schwannoma as usually slow-growing and non-metastatic, while acknowledging that growth behaviour and symptom progression vary between people.
• Explain that current useful hearing, tumour anatomy, age, comorbidity and patient goals all influence the balance of benefit and harm.

3 · Compare the pathways

• Active surveillance uses planned MRI, hearing review and symptom follow-up; it avoids immediate intervention but accepts uncertainty, repeated monitoring and possible later treatment.
• Stereotactic treatment aims for tumour control rather than removal and microsurgery aims at resection; both require specialist discussion of facial function, hearing, balance, headache, CSF leak and other individual risks.

4 · Make the decision person-centred

• Ask which outcomes matter most—hearing preservation, tumour removal, avoiding intervention, work, caring duties, travel for follow-up or tolerance of uncertainty.
• Use absolute, centre-specific outcome estimates where available, explain that hearing may decline with any pathway, and offer a second conversation rather than pressuring an immediate choice.

5 · Close with ownership

• Arrange named skull-base MDT/neuro-otology review and accessible written information; document questions and whether the person wants family involved.
• Safety-net new facial weakness or numbness, severe or changing headache, marked gait deterioration, acute neurological symptoms or sudden hearing change through the appropriate urgent route.

1 · Declare and mobilise

• Call the emergency team, senior anaesthetist and senior thyroid/ENT surgeon immediately; state ‘post-thyroidectomy haematoma with airway compromise’ and allocate roles.
• Bring the post-thyroid surgery emergency box and difficult-airway/major-haemorrhage resources according to local policy.

2 · Assess while treating

• Use the DESATS warning pattern—difficulty swallowing/discomfort, rising early-warning score, swelling, anxiety, tachypnoea/difficulty breathing and stridor—while recognising that deterioration can be rapid.
• Give high-concentration oxygen, sit the patient up if tolerated, apply full monitoring and obtain IV access without allowing these actions to delay decompression.

3 · Decide on immediate wound opening

• If airway compromise is present or deterioration continues, open the superficial wound at the bedside using the guideline’s SCOOP sequence and evacuate clot; do not transfer for imaging first.
• The trained responder acts within the emergency protocol while anaesthetic and surgical teams prepare definitive airway control and haemostasis.

4 · Coordinate airway and definitive care

• Pre-oxygenate and plan intubation with the most experienced available anaesthetist; expect distortion and a difficult airway, with front-of-neck access capability immediately available.
• Proceed to theatre for exploration and haemostasis once oxygenation is secured, while correcting coagulopathy and replacing blood products when clinically indicated.

5 · After the crisis

• Document recognition time, physiological changes, calls, wound opening, airway interventions, blood loss and team decisions; arrange critical-care monitoring.
• Explain the event honestly to the patient/family when safe, include duty-of-candour processes and conduct multidisciplinary debrief and incident review.

1 · Recognise and contain the risk

• Assess voice, stridor, drooling, posture, respiratory effort, oxygenation, mental state and sepsis while keeping the patient in their preferred position.
• Avoid unnecessary handling, forced mouth opening, tongue depression or lying flat; ensure continuous experienced observation.

2 · Escalate early

• Call senior ENT, anaesthesia and critical care and identify a location for controlled airway management with fibreoptic/video and emergency front-of-neck access capability.
• Nominate a leader, airway operator, surgical-airway operator and medication/equipment support; make the failed-airway plan explicit before deterioration.

3 · Investigate in the correct order

• Obtain blood tests, cultures and flexible nasendoscopy only if the senior airway team judges this safe and it will change immediate management.
• CT with contrast can define deep-space extent and complications in a stable, protected patient; it must not delay or destabilise airway management.

4 · Treat infection and complications

• Start sepsis care and IV antimicrobial therapy according to local policy, allergy, renal function and likely source, without allowing a search for microbiological perfection to delay treatment.
• Arrange drainage/source control with the relevant ENT, dental/maxillofacial or thoracic teams and assess for mediastinal, vascular and intracranial extension.

5 · Communicate and reassess

• Tell the patient in short sentences that swelling may affect breathing and that the senior team is preparing the safest way to examine and protect the airway.
• Document serial airway findings, response, decision points, accepting teams and transfer conditions; plan critical-care monitoring even after initial improvement.

1 · Stabilise with trauma discipline

• Use a structured trauma assessment with cervical-spine precautions appropriate to mechanism while prioritising oxygenation, voice, stridor, haemoptysis, emphysema and expanding swelling.
• Keep the patient calm, nil by mouth and continuously observed; call senior ENT, anaesthesia and trauma leadership early.

2 · Define injury without causing harm

• Document external wounds, tenderness, crepitus, laryngeal contour, voice, swallow and a full cranial-nerve/neurological baseline without repeated palpation.
• Flexible nasendoscopy may define airway mucosa and vocal-fold movement only when judged safe by an experienced team with rescue immediately available.

3 · Build the airway plan

• Use the most experienced airway and ENT clinicians, preserve spontaneous ventilation where appropriate and prepare primary and rescue plans including emergency front-of-neck access.
• Avoid blind or repeated intubation attempts that can convert partial disruption into complete obstruction or create a false passage.

4 · Image and treat once safe

• After airway stability, CT neck with appropriate vascular assessment can define cartilage, soft-tissue and associated injuries; investigate oesophageal injury when the history or findings suggest it.
• The ENT trauma team determines observation, endoscopic assessment, repair or stenting according to injury grade; admit all suspected significant cases for serial airway observation.

5 · Communicate consequences and follow-up

• Explain immediate airway risk and later voice/swallow consequences without promising recovery; involve speech-and-language therapy when appropriate.
• Record the mechanism, serial airway findings, airway plan, injuries, procedures and named follow-up for voice, airway stenosis and swallowing.

1 · Establish urgency and function

• Ask about visual loss, diplopia, eye pain/proptosis, facial numbness, severe headache, epistaxis volume, dental symptoms, smell, weight loss and airway impact.
• Document visual acuity, pupils, eye movements, fields where possible, facial sensation and other cranial nerves; urgent ophthalmic/skull-base escalation follows objective visual or neurological compromise.

2 · Take a complete exposure history

• Clarify duration and type of wood-dust and other occupational exposure, smoking, previous sinonasal disease, treatment and PPE without presenting exposure as proof of diagnosis.
• Record employer/work context sensitively and consider occupational-health support after immediate clinical priorities.

3 · Examine and image safely

• Perform nasal endoscopy only within competence and record site, surface, bleeding and surrounding anatomy without traumatic manipulation.
• Use contrast CT and MRI in complementary fashion to define bone, orbit, skull base, dura, perineural spread and nodal disease, guided by the specialist MDT.

4 · Plan tissue diagnosis and staging

• Plan biopsy after imaging in a specialist setting, considering vascularity, access and a tract that will not compromise definitive treatment.
• Complete histology-appropriate staging and discuss at a specialist sinonasal/skull-base MDT with ENT, radiology, pathology, oncology, neurosurgery and ophthalmology as required.

5 · Explain the pathway

• Tell the patient that cancer is a serious possibility but histology and staging are required before treatment can be recommended; avoid forecasting resectability from symptoms alone.
• Offer a named key worker, support for vision/nutrition and clear safety-netting for visual change, heavy bleeding, severe headache, neurological symptoms or airway deterioration.

1 · Address present safety

• Assess positional breathlessness, stridor, voice, secretion handling, aspiration, intake, weight loss and rate of progression; arrange immediate senior airway review if compromise is suspected.
• Document flexible laryngoscopy findings, both vocal folds and baseline voice/swallow function, with speech-and-language and nutrition input when required.

2 · Complete diagnosis and staging

• Review ultrasound and cytology/histology within the thyroid MDT and avoid assuming tumour type from clinical aggression alone.
• Use contrast CT or MRI for suspected T3/T4, nodal or metastatic disease, defining tracheal, oesophageal, vascular, mediastinal and neural relationships before intervention.

3 · Frame resectability and treatment

• Discuss at a specialist MDT with thyroid/ENT surgery, endocrinology, oncology, radiology, pathology, anaesthesia and relevant reconstructive teams.
• Explain that surgery, radioactive iodine, radiotherapy, systemic treatment or symptom-focused approaches depend on histology, stage, iodine avidity, fitness, resectability and the patient’s goals.

4 · Support valid consent

• Discuss voice, swallow, airway, calcium/parathyroid, nerve and reconstruction implications in person-specific terms, including how pre-existing unilateral vocal-fold dysfunction changes risk.
• Avoid ‘good cancer’; acknowledge that some thyroid cancers are highly treatable while this person’s outlook and choices require complete staging and pathology.

5 · Plan continuity

• Name the responsible key worker and arrange airway/swallow/nutrition support while the MDT decision is pending; consider palliative-care input for symptom burden alongside active treatment.
• Document the patient’s priorities, capacity, supporters, uncertainty and explicit emergency triggers including worsening stridor, inability to swallow saliva or rapidly increasing swelling.

1 · Define the functional risk

• Clarify onset, progression, aspiration symptoms, chest infections, breathlessness/stridor, cough strength, dysphagia, odynophagia, otalgia, pain and weight trajectory.
• Arrange urgent assessment for airway compromise or an unsafe swallow; involve speech-and-language therapy for instrumental assessment when clinically indicated.

2 · Confirm and localise

• Review laryngoscopy for position, glottic closure, mucosal lesion and contralateral movement; use stroboscopy or laryngeal EMG selectively through the specialist service.
• Examine oral cavity, neck, thyroid and all cranial nerves, looking for high vagal signs, skull-base features and associated neurological disease.

3 · Search the nerve pathway

• Review surgery, intubation, trauma, viral/neurological history and malignancy risk, but do not label the condition idiopathic from history alone.
• Arrange appropriate contrast imaging from skull base through neck and upper mediastinum/chest according to laterality and local pathway, plus targeted thyroid/chest investigation when indicated.

4 · Treat the person while investigating

• Provide voice conservation and specialist voice therapy advice rather than whispering or unstructured rest; address hydration, reflux contributors only when clinically relevant and nutrition.
• For significant glottic insufficiency or aspiration, discuss early temporary injection augmentation; framework surgery or reinnervation depends on cause, recovery expectation, anatomy, needs and expertise.

5 · Explain and follow through

• Tell the patient that the fold is not moving normally and that possible causes lie anywhere along the nerve pathway; cancer is one possibility, not a conclusion.
• Name who responsibility for results, repeat laryngoscopy and swallow/voice review, and safety-net breathing deterioration, inability to swallow, haemoptysis or new neurological symptoms.

1 · Stabilise and protect

• Complete primary trauma assessment with cervical-spine and head-injury considerations, control external bleeding and avoid pressure on a potentially injured globe.
• Record visual acuity in each eye, pupils including RAPD, colour/subjective vision, eye movements, proptosis, pain, globe contour and visual fields where possible before swelling or treatment obscures the baseline.

2 · Identify sight-threatening patterns

• Treat reduced acuity, RAPD, tense proptosis, severe pain, restricted movements or rapidly increasing swelling as requiring immediate senior ophthalmic and trauma escalation.
• If orbital compartment syndrome is diagnosed clinically, time-critical decompression follows the local emergency protocol and competent senior team; do not wait for CT when vision is threatened.

3 · Define facial injury

• Examine malar projection, orbital rim/step, infraorbital sensation, mouth opening, occlusion, dental injury, nasal injury, CSF-leak features and other cranial nerves.
• Advise no nose blowing and avoid actions that raise sinonasal pressure while orbital communication is possible.

4 · Image and coordinate

• Once immediate threats are addressed, obtain thin-slice CT of facial bones/orbits and relevant head/cervical imaging according to mechanism; interpret with the clinical ocular findings.
• Coordinate ophthalmology and oral-maxillofacial/craniofacial or ENT teams; timing of repair depends on vision, entrapment, globe position, diplopia, occlusion, displacement and swelling.

5 · Communicate and follow up

• Explain that protecting vision comes before deciding whether the cheekbone fracture needs surgery; avoid promising that repair will fully correct diplopia or numbness.
• Document serial visual observations, specialist decisions, precautions and named follow-up for vision, diplopia, enophthalmos, sensation, occlusion and psychosocial impact.

1 · Re-establish risk and phenotype

• Confirm AHI/ODI, symptoms, nocturnal hypoventilation risk, comorbidity, alcohol/sedatives, occupation, driving and the anatomical examination; do not use Epworth score alone to diagnose or grade OSA.
• Check whether obesity hypoventilation, central events or cardiopulmonary disease changes the treatment pathway.

2 · Understand apparent CPAP failure

• Review mask fit, pressure comfort, nasal obstruction/rhinitis, dryness, claustrophobia, adherence data and the education/support already provided.
• Optimise interface, humidification, rhinitis treatment, telemonitoring or pressure mode through the sleep team before declaring CPAP impossible.

3 · Compare reasonable alternatives

• Discuss weight and lifestyle support, a customised mandibular advancement splint when dentally suitable, and positional therapy for appropriate mild or moderate positional disease.
• NICE supports considering tonsillectomy for large obstructive tonsils with BMI below 35, and oropharyngeal-surgery assessment for selected moderate or severe OSA when CPAP and mandibular options are unsuitable or not tolerated.

4 · Select surgery responsibly

• Use awake examination and specialist sleep-surgery assessment, with further dynamic assessment only when it will change the plan; match the procedure to the likely collapse pattern rather than offering a generic operation.
• Explain pain, bleeding, swallowing/voice change, residual OSA and possible ongoing device treatment; quote centre-specific outcomes rather than guaranteeing cure.

5 · Close the safety loop

• Give clear driving and vigilance-critical work advice consistent with current DVLA guidance and document it.
• Plan objective post-treatment reassessment, symptom review and long-term weight/comorbidity care; clinical improvement alone does not prove resolution.

1 · Triage airway and function

• Clarify stridor at rest, work of breathing, rapid progression, dysphagia, haemoptysis, pain, weight loss and exercise limitation; escalate acute airway concern immediately.
• Record voice impact, occupation, prior procedure frequency, airway sites, histology, HPV typing where available, smoking and previous adjuvant treatment.

2 · Map disease safely

• Perform flexible laryngoscopy with recording only under valid consent and governance, documenting airway calibre, subsites, vocal-fold mobility and surface change.
• Plan microlaryngoscopy/bronchoscopy when distal disease or tissue diagnosis requires it, with an airway and laser/surgical safety briefing.

3 · Define operative goals

• Debulk enough to maintain airway and voice while preserving normal mucosa and the anterior/posterior commissures; avoid a pursuit of macroscopic perfection that creates stenosis or scarring.
• Select cold instruments, microdebrider, laser or other energy according to site, expertise and previous tissue effect, recognising that repeated surgery is often required.

4 · Handle atypia and adjuvants

• Send representative tissue when diagnosis, change in appearance or malignant transformation is a concern and escalate atypia through the head-and-neck pathway.
• Discuss adjuvant or intralesional/systemic therapies only through an experienced RRP service, explaining licence, evidence, contraindications and monitoring; do not describe them as cure.

5 · Build longitudinal care

• Coordinate laryngology, speech-and-language therapy and anaesthesia, using agreed airway/voice outcomes and procedure intervals rather than lesion appearance alone.
• Explain red flags, document recurrence expectations and provide named rapid access for worsening stridor, haemoptysis, swallowing change or rapid voice deterioration.

1 · Recognise and risk-stratify

• Clarify stridor at rest, speech limitation, sleep symptoms, secretion handling, infection, exertional ceiling and tempo; observe work of breathing and oxygenation without relying on saturation alone.
• Escalate rapidly progressive or resting symptoms to a controlled airway setting and avoid sedation outside a senior airway plan.

2 · Establish cause and function

• Review duration, tube size where known, re-intubation, tracheostomy, cuff injury, airway trauma, reflux/autoimmune history and previous imaging.
• Record voice, swallow, cough and aspiration symptoms because airway treatment can alter all three.

3 · Define the stenosis

• Use awake flexible endoscopy to assess laryngeal movement and visible airway; flow-volume loops and imaging can support localisation but do not replace endoscopic assessment.
• Plan microlaryngoscopy and bronchoscopy by an experienced team to document level, length, circumference, maturity, cartilage support and distance from vocal folds/tracheostomy.

4 · Select treatment through MDT

• Discuss observation only for carefully selected stable mild disease; endoscopic dilation/incision or adjuncts suit some short/simple lesions but recurrence and repeated procedures must be explained.
• Complex, long, framework-damaged or recurrent stenosis may require open reconstruction or resection; airway, anaesthetic, thoracic and rehabilitation expertise and patient goals determine choice.

5 · Measure outcomes and safety-net

• Agree outcomes in breathlessness, exercise, voice, swallowing, procedure burden and decannulation rather than lumen size alone.
• Provide rapid-access instructions for worsening stridor, inability to speak in sentences, secretion difficulty or acute respiratory deterioration and ensure a shared difficult-airway record.

1 · Reassess risk and function

• Clarify progression, pain, odynophagia, referred otalgia, haemoptysis, weight loss, breathing and swallowing; document smoking, alcohol, occupational voice demand and previous procedures.
• Record high-quality laryngoscopy/stroboscopy where appropriate, lesion site, surface, vascular pattern, mobility and the remainder of the upper aerodigestive tract.

2 · Establish reliable pathology

• Obtain and review the original histology in the head-and-neck MDT, noting grade, margin context, specimen adequacy and clinicopathological concordance.
• Repeat microlaryngoscopy with targeted biopsy or excision when persistence, progression, suspicious morphology or discordance remains, preserving layered anatomy and avoiding unnecessary thermal injury.

3 · Stratify rather than label

• Explain that dysplasia is precancerous change with variable behaviour; absence of invasion in one sample does not guarantee that the lesion will never progress.
• Escalate invasive disease to staging and the laryngeal-cancer MDT; do not use repeated superficial ablation to postpone adequate diagnosis.

4 · Reduce modifiable risk and preserve voice

• Offer active tobacco-dependence treatment and alcohol support where relevant, and involve specialist voice therapy for efficient technique and rehabilitation.
• Discuss excision/laser and surveillance trade-offs using histology, recurrence, distribution, anterior-commissure involvement, voice need and patient preference.

5 · Make surveillance explicit

• Set a named schedule of endoscopic review adjusted to grade and behaviour, with photographic comparison and low threshold for re-biopsy when morphology changes.
• Safety-net increasing dysphonia, pain, swallowing difficulty, haemoptysis, neck lump or breathing change and document who owns results and recall.

1 · Screen immediate danger

• Ask about stridor, orthopnoea, dyspnoea, dysphagia, voice change, facial/neck swelling and inability to lie flat; these may indicate airway or mediastinal compromise.
• If present, involve senior paediatrics, ENT, anaesthesia and oncology before sedation, supine imaging or theatre transfer.

2 · Build a paediatric differential

• Clarify growth, tenderness, infection/TB exposure, travel, cat contact, dental/skin disease, fever, weight, night sweats, bruising and bone pain.
• Examine size, site, consistency, fixation and skin, all nodal basins, liver/spleen, oral cavity, tonsils, scalp and cranial nerves while preserving the child’s comfort.

3 · Investigate proportionately

• Arrange FBC and film, inflammatory markers, LDH and targeted infection testing with paediatric guidance; a chest radiograph may be important before procedures when lymphoma/mediastinal disease is possible.
• Ultrasound characterises the lesion and guides next steps but cannot reliably exclude malignancy; cross-sectional imaging follows anatomy and specialist planning.

4 · Secure diagnosis safely

• Discuss tissue strategy with paediatric ENT/oncology, radiology and pathology; choose image-guided sampling or excision according to suspected diagnosis and the need for architecture.
• Avoid unplanned open biopsy that compromises oncological surgery, and avoid repeated empirical antibiotics when the red-flag pattern persists.

5 · Communicate with child and family

• Explain that many childhood lumps are benign but this pattern needs urgent testing; use developmentally appropriate language and seek the child’s assent alongside parental consent.
• Name the coordinating team, expected sequence and emergency triggers, and provide active follow-up rather than asking the family to chase results.

1 · Define tumour and host risk

• Review lesion diameter, depth, differentiation, margins, perineural/lymphovascular invasion, cartilage involvement, recurrence and the exact immunosuppressive condition and medicines.
• Examine the entire skin field, pinna/canal, parotid and all neck levels, recording facial and trigeminal nerve function and pain/numbness.

2 · Establish regional disease

• Arrange ultrasound-guided sampling of the parotid-region mass when appropriate and obtain contrast CT or MRI of parotid/neck, using MRI particularly when named-nerve spread is suspected.
• Stage chest/distant disease according to MDT risk assessment and ensure dermatopathology review confirms the primary’s high-risk features.

3 · Use specialist MDT planning

• Discuss in a specialist skin cancer/head-and-neck MDT with dermatology, ENT/OMFS/plastics, radiology, pathology and oncology.
• Plan primary-site clearance together with therapeutic management of involved parotid and neck basins; exact parotidectomy and neck-dissection extent follows mapped disease and functional risk.

4 · Explain multimodality trade-offs

• Discuss facial-nerve risk, auricular defect and reconstruction, shoulder function, sensation, salivary effects and wound-healing issues in immunosuppression.
• Consider postoperative radiotherapy through MDT for adverse features; systemic options for unresectable or metastatic disease require specialist oncology assessment.

5 · Coordinate survivorship

• Review immunosuppression modification only with the prescribing transplant/haematology team—never stop it unilaterally.
• Provide skin surveillance, sun-protection advice, named follow-up and safety-net new facial weakness, neuropathic pain, rapid nodal growth or ulceration.

1 · Define the phenotype

• Ask about autophony of voice/body sounds, pulsatile tinnitus, sound- or pressure-induced vertigo/oscillopsia, aural fullness, hearing change, falls and functional avoidance.
• Clarify migraine, patulous Eustachian-tube symptoms, Ménière-like episodes, previous trauma and whether symptoms localise to the imaged side.

2 · Demonstrate concordance

• Perform otoscopy, tuning-fork assessment, audiometry including apparent low-frequency conductive components and acoustic reflexes as appropriate.
• Use VEMP testing and high-resolution temporal-bone CT reformatted in the canal plane; review images with an experienced neuroradiologist because partial-volume artefact can overcall dehiscence.

3 · Explain mechanism and uncertainty

• Describe an abnormal third mobile window that changes inner-ear pressure and sound transmission, linking this to autophony and stimulus-induced vertigo.
• Explain that radiological dehiscence can be incidental and that symptoms plus physiological tests establish clinical relevance.

4 · Match treatment to burden

• For manageable symptoms, offer education, trigger modification and hearing/balance support with planned review; avoid advising disabling lifelong avoidance without discussion.
• For severe concordant disability, discuss specialist plugging/resurfacing approaches, access routes and risks including hearing loss, imbalance, facial/neurological injury, CSF leak, symptom persistence and recovery time.

5 · Agree outcomes and follow-up

• Identify the symptom the patient most wants improved and use baseline patient-reported, hearing and vestibular measures to judge benefit.
• Safety-net sudden hearing loss, new persistent neurological symptoms or acute severe imbalance through the appropriate urgent pathway.

1 · Confirm disease and contributors

• Document more than 12 weeks of blockage/discharge, smell loss and facial symptoms, endoscopy, prior CT and operation, adherence and technique with intranasal corticosteroid and irrigation.
• Reconsider unilateral disease, immunodeficiency, ciliary disease, vasculitis and odontogenic/fungal pathology when the pattern is atypical.

2 · Measure severity and type-2 context

• Record SNOT-22, smell, sleep/work impact, polyp score, systemic-steroid exposure, asthma control and exacerbations and possible NSAID-exacerbated respiratory disease.
• Coordinate respiratory/allergy review because one treatment plan should account for upper and lower airway disease and cumulative steroid harm.

3 · Explain the current NICE option

• NICE permits dupilumab added to intranasal corticosteroids for adults with severe CRSwNP uncontrolled by systemic corticosteroids or surgery, after at least one sinus operation and with SNOT-22 at least 50, subject to the commercial arrangement.
• Eligibility does not equal automatic selection: confirm contraindications, expectations, administration, adverse effects, monitoring, duration and local commissioning pathway.

4 · Compare revision surgery

• Revision endoscopic surgery can remove obstruction and improve topical access but does not remove the inflammatory tendency; recurrence and operative risks must be individualised from anatomy and prior surgery.
• A biologic avoids an operation but introduces repeated treatment, monitoring, uncertain long-term duration and variable response; incorporate the patient’s values and asthma benefit.

5 · Define response and fallback

• Agree baseline outcomes and a time-defined specialist response review using symptoms, smell, polyp burden, steroid need, asthma and adverse effects; avoid indefinite treatment without evidence of benefit.
• Continue appropriate intranasal therapy and provide safety-netting for visual symptoms, severe frontal headache, neurological signs, unilateral bleeding or acute systemic deterioration.

1 · Confirm urgency and function

• Arrange formal audiology within four weeks of being well enough, preferably before discharge, and urgent cochlear-implant assessment for severe or profound deafness.
• Document communication needs and provide accessible written, visual or interpreting support now.

2 · Define anatomy

• Review MRI for cochlear patency and auditory-nerve anatomy, adding CT when ossification or bony anatomy affects planning.
• A normal early scan does not remove the risk of evolving ossification; serial imaging is an implant-team decision.

3 · Build the MDT decision

• Combine aided speech testing, prior hearing, cognition, fitness, imaging, communication goals and rehabilitation capacity.
• Ossification may accelerate timing but does not automatically determine unilateral or bilateral implantation.

4 · Counsel beyond surgery

• Explain surgical/device risks, possible incomplete insertion, mapping and prolonged auditory rehabilitation with uncertain speech outcomes.
• Offer Deaf-informed support and communication choices without making spoken language the only measure of success.

5 · Own follow-up

• Check vaccination and meningitis-prevention arrangements through the implant pathway.
• Coordinate neurology, audiology, speech and language therapy, rehabilitation and psychosocial follow-up with named responsibility.

6 · Convert urgency into an implant strategy

• Bring the case to the cochlear-implant MDT as an urgent, named referral rather than simply requesting interval audiology. Review both cochleae for patency, the modiolus and cochlear nerves, and ask the implant surgeon to define whether the anatomy favours a standard array, an alternative array or a planned incomplete insertion.
• Laterality is an individual decision. Rapid bilateral ossification, usable anatomy and the patient's communication goals may support an early bilateral strategy, whereas medical instability or asymmetric anatomy may justify a staged plan. The answer must identify what is lost by delay without pretending that speed overrides perioperative safety.

7 · Plan the difficult insertion and rehabilitation

• Consent must cover drill-out or altered cochleostomy strategy where required, partial insertion, scalar trauma, device non-use, facial-nerve stimulation, vestibular symptoms and the possibility that a technically successful implant gives limited speech understanding. Agree the intra-operative bailout if a safe lumen cannot be developed and preserve options on the other side.
• Start communication support immediately. After activation, measure aided thresholds, speech perception, listening effort and participation over time; revise the rehabilitation plan if the expected trajectory is not achieved rather than labelling the patient a poor user.

1 · Call and prepare

• Activate senior airway, ENT, critical-care and major-haemorrhage support; bring suction, capnography, fibreoptic equipment and the bedhead plan.
• Identify why and when the stoma was made, upper-airway patency, tube type, cuff and tract maturity.

2 · Oxygenate and test patency

• Apply high-flow oxygen to face and stoma until anatomy is certain; use waveform capnography during ventilation.
• Pass a suction catheter and remove obstructing attachments or inner cannula in the NTSP sequence.

3 · Temporise safely

• Use suction and direct pressure where appropriate; cautious cuff hyperinflation by an experienced responder may temporarily tamponade major bleeding.
• Do not remove a functioning tube that may be tamponading the site without an airway rescue plan.

4 · Reach definitive control

• Move urgently toward theatre or the relevant vascular/interventional pathway with blood products; temporary control is not treatment completion.
• Plan oral intubation beyond the site only if anatomically possible and led by experienced airway clinicians.

5 · Keep reassessing

• Continue haemodynamic, airway and blood-loss reassessment even if bleeding stops.
• After survival priorities, preserve chronology and review tube position, pressure injury and prevention through governance.

6 · Lead the haemorrhage–airway choreography

• Allocate named roles: one clinician maintains oxygenation and capnography, one controls the stoma and tube, one activates major haemorrhage and blood products, and one coordinates theatre, interventional radiology and the responsible surgical service. State aloud whether this is a tracheostomy or laryngectomy because face oxygenation and oral intubation differ fundamentally.
• If major arterial erosion is suspected, leave an inflated cuff inflated and consider cautious further inflation or direct compression only as temporising measures by experienced clinicians. Definitive control must be mobilised concurrently; a transiently dry field is not permission for CT in an unstable patient.

7 · Define definitive and failed-control plans

• Agree whether the fastest definitive route is operating theatre or an interventional vascular route based on physiology, anatomy and immediate availability. If oral intubation is anatomically possible, the experienced airway operator may plan the tube distal to the bleeding site while the surgical team prepares exposure; repeated blind tube exchanges risk losing both tamponade and the airway.
• After control, document cuff pressure, tube tip and vessel relationship, correct coagulopathy and review causative factors such as low placement, tube motion or pressure injury. The surviving patient still requires a prevention and surveillance plan.

1 · Stabilise

• Assess work of breathing, speech, secretions and trajectory; prepare controlled reintubation or tracheostomy with the difficult-airway team.
• Inspect immediately for expanding neck swelling and follow the postoperative haematoma pathway without waiting for imaging.

2 · Confirm the laryngeal problem

• Use awake flexible laryngoscopy when safe, documenting position, movement, oedema and airway.
• Review operative and nerve-monitoring events, but do not treat a normal signal as proof of postoperative function.

3 · Protect recovery

• Use appropriate temporary airway support and serial reassessment because neuropraxic function may recover over months.
• Assess voice, swallowing, aspiration and calcium; involve speech and language therapy when stable.

4 · Plan long-term options

• For persistent limitation, compare continued tracheostomy with reversible or irreversible glottic-widening procedures in an airway MDT.
• Explain that cordotomy or arytenoid procedures improve breathing at possible cost to voice and airway protection.

5 · Communicate openly

• Explain the unexpected complication, separate facts from mechanism still under review and follow duty-of-candour processes.
• Create a future difficult-airway alert, review schedule and emergency instructions.

6 · Consultant synthesis

• Separate immediate airway rescue from the later diagnosis of neural paralysis versus cricoarytenoid fixation using serial endoscopy, operative history and selected EMG/examination under anaesthesia.
• Set a dated recovery window and decannulation pathway. If immobility persists, choose unilateral staged posterior cordotomy/arytenoid strategy according to glottic aperture, aspiration, voice needs and pulmonary reserve; preserve the contralateral side until outcome is known.

7 · Prove mechanism before irreversible widening

• Review serial flexible laryngoscopy for recovery and exclude posterior glottic stenosis or cricoarytenoid fixation. Laryngeal EMG may help with prognosis when interpreted in the correct time window, but it does not replace examination under anaesthesia when fixation remains possible.
• Set an explicit review interval and airway endpoint. A tracheostomy may be the safest reversible bridge while recovery remains plausible; prolonged observation without a decannulation or definitive-treatment plan is not neutral care.

8 · Choose the smallest effective definitive procedure

• For persistent neurogenic immobility, frame the choice around airway demand, baseline voice, swallowing safety, pulmonary reserve and patient priorities. A unilateral staged posterior cordotomy, with or without arytenoid work, is preferable to immediate bilateral destruction in many patients because the result can be assessed before sacrificing further voice and airway protection.
• Consent covers inadequate airway gain, granulation or restenosis, revision, dysphonia and aspiration. Stop if exposure, landmarks or tissue behaviour make the planned limited procedure unsafe; a secure tracheostomy is preferable to uncontrolled bilateral injury.

1 · Confirm and stage

• Review expert cytology, ultrasound thyroid and nodal compartments and measure calcitonin and CEA in context.
• Use cross-sectional and distant staging according to burden through the thyroid MDT.

2 · Exclude phaeochromocytoma

• Urgently assess plasma free or urinary fractionated metanephrines with endocrinology.
• If present, specialist alpha blockade and adrenal treatment precede thyroid surgery.

3 · Define MEN2

• Check calcium/parathyroid status and family history; an apparently sporadic presentation can still carry germline RET.
• Arrange counselling and germline testing with valid consent, explaining implications for surveillance and relatives.

4 · Plan surgery

• Discuss total thyroidectomy and compartment-oriented nodal surgery based on mapped disease, not indiscriminate dissection.
• Explain recurrent nerve, parathyroid, voice, swallowing and lifelong hormone consequences.

5 · Build lifelong care

• Monitor calcitonin/CEA trends with structural assessment; one biochemical threshold does not replace anatomy.
• Offer cascade testing through genetics if germline RET is found, preserving confidentiality.

6 · Consultant synthesis

• State the operative extent from mapped central/lateral nodal disease rather than calcitonin alone, and confirm laryngeal function and parathyroid plan before bilateral surgery.
• If phaeochromocytoma is identified, sequence alpha blockade and adrenal treatment first; RET result informs family surveillance but must not delay the biochemical safety step.

7 · Turn staging into a compartment operation

• Present the thyroid and nodal ultrasound map by central and lateral compartments, reconcile it with cross-sectional staging and state the operation you recommend. Total thyroidectomy is paired with nodal surgery according to clinically mapped disease; a marker level alone is not an instruction for indiscriminate lateral dissection.
• Before bilateral surgery document vocal-fold movement, calcium and vitamin-D status, operative fitness and the plan for parathyroid identification or autotransplantation if devascularised. Consent includes permanent hypoparathyroidism, bilateral nerve risk, chyle leak with lateral dissection, bleeding, lifelong thyroxine and the possibility of persistent biochemical disease.

8 · Own residual disease and the family consequence

• After surgery, interpret calcitonin and CEA trends with structural imaging rather than promising biochemical cure. Persistent or rising markers require a defined re-staging route and a decision about whether re-operation offers meaningful structural control.
• A pathogenic germline RET result activates genetics-led cascade testing and syndrome-specific surveillance for relatives. Communicate the relevance and offer support, but preserve the patient's confidentiality and do not personally contact relatives outside the agreed genetics pathway.

1 · Reconfirm extent

• Ask about pain, rapid growth, skin change and weakness; examine every facial-nerve division and the neck.
• Use expert ultrasound and MRI with image-guided sampling when needed; avoid open biopsy.

2 · Explain biology

• Rupture and satellite nodules can produce scattered late recurrence; visible nodules may underestimate distribution.
• Discuss low but real malignant concern with rapid growth, pain, fixation or nerve dysfunction.

3 · Compare routes

• Documented observation can suit small stable disease when morbidity outweighs benefit, with explicit triggers.
• Revision wide-field clearance seeks nerve preservation but carries weakness, numbness, Frey syndrome, contour loss and further recurrence.

4 · Use radiotherapy selectively

• Discuss radiotherapy for multiply recurrent, unresectable or high-morbidity disease, not every recurrence.
• Explain uncertain benign-disease evidence and late radiation effects.

5 · Follow long term

• Use prolonged clinical and imaging surveillance because recurrence can occur many years later.
• Record baseline facial function, patient priorities and recall ownership.

6 · Consultant synthesis

• Map every nodule against facial branches and distinguish macroscopic clearance from unacceptable neural morbidity; prepare monitoring, proximal/distal control and immediate graft/reanimation options without planning sacrifice of a functioning uninvolved nerve.
• Use observation or radiotherapy only through a documented specialist MDT decision with long-term imaging ownership and explicit triggers for change.

7 · Design the revision field before entering scar

• Review prior operation notes, pathology, rupture and margin history, then map each recurrent focus on MRI relative to the main trunk and peripheral facial branches. Plan exposure from unoperated landmarks where possible, facial-nerve monitoring, proximal control and access to nerve graft and reanimation expertise before incision.
• The aim is oncologically sensible gross clearance without casual sacrifice of a functioning uninvolved nerve. Multifocality may make microscopic clearance impossible; this uncertainty belongs in consent and in the MDT record rather than being discovered after surgery.

8 · Set the nerve and radiotherapy thresholds

• If tumour can be separated safely, preserve the nerve. If a branch is directly infiltrated or unavoidable sacrifice was specifically anticipated and consented, resect only with an immediate reconstruction plan. If unexpected main-trunk sacrifice would be required and the situation is not oncologically urgent, stop, obtain definitive information and re-consent.
• For multiply recurrent disease where further surgery carries disproportionate morbidity, compare active surveillance and specialist radiotherapy using growth, symptoms, malignant concern, previous treatment and the patient's priorities. Each choice needs long-term imaging ownership and explicit triggers to change course.

1 · Triage organs

• Assess stridor and subglottic airway urgently with experienced airway support.
• Check blood pressure, creatinine/eGFR, urine microscopy/protein and pulmonary, ocular, neurological and skin features.

2 · Build a non-stigmatising differential

• Consider GPA, cocaine/levamisole injury, infection, malignancy, trauma and iatrogenic causes.
• Ask about intranasal exposure without judgment and explain its clinical relevance.

3 · Obtain concordant evidence

• Use endoscopy, sinus CT and symptom-led chest/airway imaging; test PR3-/MPO-ANCA but do not use a negative result to rule out limited disease.
• Biopsy viable active tissue of adequate depth and coordinate potentially higher-yield renal or other tissue.

4 · Control disease before reconstruction

• Organ-threatening disease needs urgent specialist immunosuppression planning; ENT supports airway and local care.
• Avoid septal or saddle-nose reconstruction during active inflammation.

5 · Coordinate monitoring

• Create shared rheumatology, renal, respiratory and ENT ownership and distinguish active disease from scar damage.
• Safety-net worsening stridor, haemoptysis, oliguria, visual or neurological symptoms.

6 · Consultant synthesis

• Characterise subglottic stenosis endoscopically with an airway plan and coordinate renal biopsy when it offers higher diagnostic yield; immunosuppression and airway intervention may need to proceed in parallel in organ-threatening disease.
• Reconstruction requires sustained disease quiescence, realistic vascular/tissue assessment and agreement that appearance will not be pursued at the cost of reactivating injury or losing airway access.

7 · Separate inflammatory activity from fixed damage

• Describe whether the airway problem is oedematous active disease, mature circumferential scar or a mixed lesion because immunosuppression and mechanical intervention answer different problems. Use endoscopy and cross-sectional assessment with anaesthetic planning; do not repeatedly instrument a critically narrow airway to improve descriptive detail.
• Renal impairment, active urinary sediment, pulmonary haemorrhage, orbital threat or progressive neuropathy makes this organ-threatening disease and demands urgent rheumatology–renal treatment in parallel with ENT airway protection. A negative ANCA or superficial necrotic biopsy must not create false reassurance when the phenotype is compelling.

8 · Define airway intervention and reconstruction boundaries

• For fixed symptomatic subglottic stenosis, choose endoscopic dilation, scar treatment or open reconstruction according to length, grade, cartilage support, prior procedures and disease activity. State the rescue airway if induction or dilation fails; tracheostomy may be necessary but is not a substitute for systemic control.
• Delay nasal framework reconstruction until sustained clinical quiescence, stable immunosuppression and adequate tissue quality. Explain that reconstruction cannot safely proceed while destructive inflammation or ongoing intranasal injury remains active.

1 · Verify anatomy and development

• Review expert MRI/CT, electrophysiology, behavioural audiology, hearing-aid verification and developmental assessment.
• Investigate syndromic/genomic causes and assess vision, balance and additional needs.

2 · Explain the distinction

• A cochlear implant stimulates the cochlea via the auditory nerve; ABI bypasses both and stimulates the cochlear nucleus.
• ABI is intracranial, with neurological, non-auditory stimulation, programming and outcome uncertainties.

3 · Refer through the specialist service

• Refer early to the NHS England highly specialised paediatric ABI MDT rather than selecting surgery locally.
• Include skull-base ENT, neurosurgery, audiology, neuroradiology, paediatrics, speech/language, education and psychology.

4 · Consent realistically

• Benefit may range from sound awareness to limited speech perception; open-set speech cannot be guaranteed.
• Compare risk and rehabilitation burden with non-implant communication routes using Deaf-informed support.

5 · Protect language

• Continue accessible total communication and early language exposure during assessment.
• Measure auditory, language, social and family outcomes longitudinally as the child’s own preferences emerge.

6 · Consultant synthesis

• Require expert MRI review because an apparently absent nerve may be hypoplastic; relate cochlear anatomy, electrophysiology and developmental profile to whether CI trial, ABI assessment or non-device communication is rational.
• Consent explicitly covers craniotomy, CSF leak, cranial-nerve/brainstem injury, non-auditory stimulation, repeated programming and the possibility of sound awareness without useful speech.

7 · Make candidacy anatomy-led and development-led

• Ask expert neuroradiology to distinguish aplasia from severe hypoplasia and confirm cochlear, internal auditory canal and brainstem anatomy. Reconcile imaging with electrophysiology, aided behavioural responses and the child's developmental profile; no single test should be used to promise or deny meaningful benefit.
• A cochlear-implant trial may be rational in selected hypoplastic-nerve cases, while clear bilateral absence with an anatomically accessible cochlear nucleus may support ABI assessment. The recommendation belongs to the highly specialised service and must include a credible non-device communication plan.

8 · Describe the ABI pathway rather than naming the device

• Explain the combined skull-base and neurosurgical approach, placement on the cochlear nucleus and the use of intra-operative electrophysiology to guide positioning. Consent covers craniotomy, CSF leak, lower cranial-nerve or brainstem injury, non-auditory stimulation, device failure and the possibility that electrodes must be disabled.
• Initial activation and repeated programming need specialist monitoring because stimulation may cause throat sensation, dizziness, twitching or cardiorespiratory effects. Success should include safe device use, sound awareness, communication participation and family goals—not open-set speech alone.

1 · Confirm recurrence and resectability

• Use expert examination/biopsy and contrast local, neck and distant staging, comparing original treatment fields.
• Assess cartilage/extralaryngeal extension, nodes, achievable margins and radionecrosis.

2 · Assess the person

• Evaluate frailty, cardiopulmonary reserve, nutrition, aspiration, baseline function, support and rehabilitation goals.
• Involve SLT, dietetics, anaesthesia and specialist nursing before consent.

3 · Compare salvage routes

• Selected small accessible recurrences with preserved function may suit transoral or open partial salvage in expert regional services.
• Advanced resectable disease after radiotherapy generally needs total laryngectomy; a retained but aspirating larynx is not functional preservation.

4 · Mitigate complications

• Explain wound breakdown, pharyngocutaneous fistula, prolonged stay, swallowing rehabilitation and stricture risk.
• Consider vascularised tissue reinforcement and plan stoma, pulmonary and voice rehabilitation.

5 · Preserve real choice

• If unresectable or surgery declined, discuss systemic treatment, selected re-irradiation, symptom control and early palliative care without implying equivalent cure.
• Document expected outcomes, uncertainty, second opinion and urgent routes for airway, bleeding or aspiration deterioration.

6 · Consultant synthesis

• State whether the recurrence is suitable for transoral/partial salvage or total laryngectomy using exposure, cartilage/extralaryngeal extent, margins and baseline aspiration—not patient preference alone.
• Plan vascularised tissue reinforcement in the irradiated field when risk supports it, and pre-plan management of fistula, exposed carotid, nutrition, thyroid dysfunction and voice restoration.

7 · State the salvage operation and reconstruction