AAO-HNSF clinical practice guidelines: selected key action statements for ENT practice

Key points

In sudden sensorineural hearing loss, routine head CT and routine laboratory tests are not recommended; audiometry should be obtained as soon as possible, within 14 days of symptom onset.
In posterior canal BPPV, diagnosis with the Dix-Hallpike manoeuvre and treatment with canalith repositioning are strong recommendations; routine imaging and vestibular suppressants are not recommended.
The 2025 adult sinusitis update emphasises watchful waiting for uncomplicated acute bacterial rhinosinusitis and, if an antibiotic is used, amoxicillin with or without clavulanate as first line.
Laryngoscopy is recommended for dysphonia that does not resolve within 4 weeks; an adult neck mass without an infectious history that persists for 2 weeks or more should be treated as at increased risk for malignancy.

How the guidelines are developed

These guidelines follow the Foundation's "Clinical Practice Guideline Development Manual" (third edition, 2013). Guideline groups include otolaryngologists together with family medicine, paediatrics, audiology, radiology, nursing and other disciplines, as well as patient/consumer advocates. Each recommendation comes with an action statement profile describing benefits, harms and costs, patient preferences, confidence in the evidence and any differences of opinion within the group.

Aggregate evidence quality is generally graded from A to D: grade A refers to systematic reviews of well-designed randomised or diagnostic studies, grade D to expert opinion and case series; grade X is used for exceptional situations where validating studies cannot be performed and benefit clearly predominates. Strength is expressed in three main tiers:

Strong recommendation: benefits clearly exceed harms and the evidence is generally of high quality; strong recommendations can also be made against an action.
Recommendation: the balance of benefit and harm favours the action but the evidence is more limited; clinicians would generally be expected to follow it.
Option: the evidence is weak or the balance of benefit and harm is unclear; the decision rests on clinical judgement and patient preference.

Otology and balance

Sudden hearing loss (2019 update, age ≥18)

Conductive and sensorineural hearing loss should be distinguished at first presentation (strong recommendation); bilateral or recurrent loss and focal neurological findings should be sought by history and examination.
Routine non-targeted head CT and routine laboratory testing are not recommended (strong recommendation against); retrocochlear pathology should be evaluated with MRI or auditory brainstem response (ABR).
Corticosteroids may be offered as an option within 2 weeks of onset; intratympanic steroid is recommended when recovery is incomplete 2 to 6 weeks after onset. Antivirals, thrombolytics, vasodilators and vasoactive agents should not be given routinely.
Follow-up audiometry should be obtained at the end of treatment and within 6 months of completing it; patients with residual hearing loss or tinnitus should be counselled about audiological rehabilitation.

Benign paroxysmal positional vertigo (2017 update, age ≥18)

Posterior canal BPPV is diagnosed when the Dix-Hallpike manoeuvre provokes vertigo with torsional, upbeating nystagmus (strong recommendation); if nystagmus is horizontal or absent, a supine roll test for lateral canal BPPV is recommended.
Treatment is a canalith repositioning procedure (strong recommendation); post-procedural postural restrictions are not recommended (strong recommendation against).
In a patient who meets diagnostic criteria without inconsistent findings, imaging, vestibular testing and routine vestibular suppressants are not recommended; the patient should be reassessed within 1 month.

Rhinology and larynx

Adult sinusitis (2025 update; previous version 2015)

ABRS is diagnosed when signs of acute rhinosinusitis persist without improvement for at least 10 days after the onset of upper respiratory symptoms, or worsen within 10 days after initial improvement ("double worsening") (strong recommendation). Imaging is not obtained unless a complication or alternative diagnosis is suspected.
Watchful waiting without antibiotics, with assured follow-up, should be offered for uncomplicated ABRS; if an antibiotic is chosen, amoxicillin with or without clavulanate for 5 to 7 days is first line for most adults. If there is no improvement after 3 to 5 days of appropriate antibiotic, the patient is reassessed.
Chronic rhinosinusitis (CRS) should be confirmed with objective evidence of sinonasal inflammation by anterior rhinoscopy, nasal endoscopy or CT (strong recommendation), and the presence or absence of nasal polyps should be established.
Saline irrigation and/or topical intranasal steroids are recommended for CRS; antifungal therapy is not. Biologics should not be routinely prescribed for CRS without polyps; patients with CRS with polyps should be informed about biologics when prior medical and surgical therapy has failed or surgery is not suitable.

Hoarseness / dysphonia (2018 update, all ages)

Factors that warrant expedited laryngeal evaluation should be sought, including recent head, neck or chest surgery or intubation, a concomitant neck mass, respiratory distress or stridor, tobacco use and professional voice use (strong recommendation).
Laryngoscopy should be performed, or the patient referred, when dysphonia fails to resolve within 4 weeks or whenever a serious cause is suspected; diagnostic laryngoscopy is also recommended before voice therapy.
CT/MRI should not be ordered, and antireflux medication or corticosteroids should not be prescribed on symptoms alone, before the larynx is visualised; antibiotics are not routinely recommended (strong recommendation against). Voice therapy is advocated for amenable causes (strong recommendation), surgery for selected conditions and botulinum toxin for laryngeal dystonia.

Paediatric ENT

Tonsillectomy in children (2019 update, ages 1–18)

For recurrent throat infection, watchful waiting is recommended if there were fewer than 7 episodes in the past year, fewer than 5 per year in the past 2 years or fewer than 3 per year in the past 3 years (strong recommendation). Tonsillectomy is an option when these thresholds are met and each episode is documented with at least one of temperature >38.3 °C, cervical adenopathy, tonsillar exudate or a positive group A streptococcal test.
In obstructive sleep-disordered breathing, preoperative polysomnography is recommended for children under 2 or with obesity, Down syndrome, craniofacial anomalies, neuromuscular disorders, sickle cell disease or mucopolysaccharidoses; tonsillectomy is recommended for OSA documented by polysomnography.
A single intraoperative dose of intravenous dexamethasone and postoperative ibuprofen and/or acetaminophen are strong recommendations; perioperative antibiotics are not recommended and codeine must not be used under age 12. Children under 3 or with severe OSA (AHI ≥10 or oxygen saturation nadir <80%) should be monitored overnight as inpatients.

Tympanostomy tubes (2022 update, 6 months–12 years)

Tubes should not be inserted for a single episode of otitis media with effusion (OME) lasting less than 3 months; a hearing evaluation should be obtained if OME persists for 3 months or longer or when the child becomes a tube candidate.
Bilateral tubes should be offered for bilateral OME of 3 months or longer with documented hearing difficulty; in recurrent acute otitis media, tubes are offered only if middle ear effusion is present at the time of assessment.
Topical antibiotic ear drops alone, without oral antibiotics, are strongly recommended for uncomplicated acute tube otorrhoea; routine postoperative drops and routine prophylactic water precautions are not recommended.

Neck mass in adults (2017, age ≥18)

A mass without an infectious history that has persisted for 2 weeks or more without significant fluctuation, or of uncertain duration, and fixation, firm consistency, size over 1.5 cm or ulceration of the overlying skin indicate increased risk for malignancy.
Contrast-enhanced neck CT (or MRI) is a strong recommendation for patients at increased risk; a targeted examination visualising the mucosa of the larynx, base of tongue and pharynx should be performed.
When the diagnosis is uncertain, fine-needle aspiration (FNA) should be used instead of open biopsy and a cystic mass should not be assumed benign; if FNA and imaging fail to give a diagnosis or primary site, examination of the upper aerodigestive tract under anaesthesia is recommended before open biopsy.
Antibiotics should not be prescribed routinely unless there are signs of bacterial infection.

Implications for practice

The guidelines are written for the US health system, but their shared messages—avoiding unnecessary imaging and antibiotics, not delaying time-sensitive steps (audiometry in sudden hearing loss, laryngoscopy in dysphonia) and not losing time on empirical treatment of an adult neck mass before malignancy is excluded—translate well to practice in Turkey.

Drug licensing and reimbursement (for example for biologics), access to services such as polysomnography and referral pathways differ between countries, so the recommendations should be weighed against local conditions.

Limitations and currency

Guidelines are updated periodically; the years given here reflect the AAO-HNSF list as of November 2026, when this text was prepared. As the 2025 update of the adult sinusitis guideline shows, recommendations can change; the current full text on entnet.org and in Otolaryngology–Head and Neck Surgery should be checked before applying them.

This summary gives only selected key action statements in abbreviated form; the scope, exclusions and target age group of each recommendation are defined in the full text. Guidelines do not replace clinical judgement.

Sources

The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.