When to refer to ENT: urgent and routine
- Topic
Some ear, nose and throat problems must be seen the same day; others within days or weeks. This table helps you decide.
What it is
In primary care most ear, nose and throat problems are managed without a specialist, but a few threaten the airway, hearing, the facial nerve or life, and others may be cancer. This page gathers the referral criteria in one table with their urgency: same day (emergency department or immediate ENT), urgent (within a few days) and routine (booked appointment). Each row points to the page for that complaint or emergency for management.
Key facts
- The WHO notes that many low- and middle-income countries have less than one ENT specialist and one audiologist per million people: referring well is part of quality care.
- A useful referral states the specific question, how long the problem has lasted, the findings and the tests done (for example, the audiogram).
- The WHO advises not to ignore fluid or pus from the ear: untreated infections can have serious complications.
- In nosebleeds, the need for emergency care is defined by bleeding that does not stop after 20 minutes of pressure, head injury or anticoagulant use.
Step by step
- Airway first: stridor, drooling or breathing difficulty go to the emergency department without delay.
- Next, look for risk of losing function: sudden hearing loss or facial palsy.
- Then look for signs of cancer: persistent, one-sided symptoms, with tobacco, alcohol or older age.
- If there is no red flag, treat in primary care and book a dated review.
- Refer routinely what does not improve with first-line treatment or needs a procedure.
- Write the question, the urgency and the key findings in the referral.
Criteria for referral to ENT by urgency
| Situation | Urgency | Why |
|---|---|---|
| Sudden sensorineural hearing loss (over hours or a few days) | Same day | Early treatment improves recovery |
| Stridor, drooling, difficulty swallowing saliva or breathing | Same day (emergency department) | Risk of sudden airway obstruction |
| One-sided sore throat with trismus, muffled voice and deviated uvula | Same day | Peritonsillar abscess: drainage and airway risk |
| Otitis with swelling or redness behind the ear, or facial palsy | Same day | Mastoiditis and its complications (meningitis, abscess) |
| Nosebleed not stopping after 20 minutes of pressure, after head injury or on anticoagulants | Same day (emergency department) | Active bleeding; after trauma there may be a fracture |
| Neck lump, mouth ulcer or red or white patch that does not heal, persistent hoarseness or painful swallowing | Urgent (days) | Suspected head and neck cancer |
| Persistent or recurrent ear discharge | Urgent (days) | An untreated infection can become complicated |
| Abnormal newborn hearing screen confirmed on repeat | Urgent (diagnosis before 3 months) | 1-3-6 principle |
| Asymmetric hearing loss (15 dB or more between ears at 500 to 2000 Hz) | Routine | Not typical of presbycusis or noise; needs investigation |
| Audiometric criteria from a hearing conservation programme | Routine | Confirm NIHL and exclude other causes |
In clinical practice
- In epiglottitis the tongue must not be pressed down to look at the throat: it can trigger obstruction; the airway is secured in a prepared setting.
- Otitis that does not respond to treatment or is followed by new symptoms (headache, fever, facial asymmetry) should raise suspicion of mastoiditis.
- In sudden unilateral hearing loss, a tumour of the auditory nerve is looked for once the emergency is over.
- Head and neck cancer symptoms may have benign causes, but if they persist they are investigated; chronic sinus infection that does not respond to antibiotics is also a red flag.
Next step / Initial management
- Before referring: otoscopy, anterior rhinoscopy, examination of the mouth and neck, and audiometry if the problem is hearing and not urgent.
- While referring: secure the airway, compress a nosebleed with the patient leaning forward, and control pain and fever.
- Same-day referral: airway compromise, sudden hearing loss, peritonsillar abscess, mastoiditis, facial palsy or a nosebleed that does not stop.
- Urgent referral (within days): suspected head and neck cancer; persistent ear discharge; abnormal newborn screen.
- Routine referral: asymmetric or progressive hearing loss, occupational audiometric criteria and problems that do not respond to initial treatment.
Test yourself
Think of the answer, then tap the question to see it.
A 45-year-old man wakes with hearing loss in the right ear; otoscopy is normal and Weber lateralises to the left. How urgently is he referred?
The same day. This is sudden sensorineural hearing loss, an emergency: treatment loses effect if delayed beyond two to four weeks.
A child with high fever, drooling, stridor and sitting forward arrives in clinic. What must not be done and where does the child go?
Do not press the tongue down with a depressor to look at the throat, as it can trigger obstruction. The child goes straight to the emergency department to secure the airway in a prepared setting.
A 60-year-old smoker has had hoarseness for 6 weeks without infection. What is the next step?
Urgent referral to ENT for laryngoscopy: persistent hoarseness in a smoker is a red flag for laryngeal cancer.
A woman reports slowly progressive hearing loss in the left ear only. How urgently is she referred and why?
Routinely, with an audiogram. An asymmetric loss does not fit presbycusis or noise, which are bilateral and symmetric, and needs ENT investigation.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Sudden Deafness (National Institute on Deafness and Other Communication Disorders (NIDCD), 2018); Epiglottitis (MedlinePlus, U.S. National Library of Medicine, 2026); Peritonsillar abscess (MedlinePlus, U.S. National Library of Medicine, 2024); Mastoiditis (MedlinePlus, U.S. National Library of Medicine, 2026); Nosebleed (MedlinePlus, U.S. National Library of Medicine, 2025); Head and Neck Cancers (fact sheet) (National Cancer Institute, 2021); Deafness and hearing loss: ear care (questions and answers) (World Health Organization, 2026); Guía de Atención Integral Basada en la Evidencia para Hipoacusia Neurosensorial Inducida por Ruido en el Lugar de Trabajo (GATI-HNIR) (Ministerio de la Protección Social, República de Colombia, 2006); Resolución 207 de 2024: lineamientos técnicos y operativos del Programa de Tamizaje Neonatal (Ministerio de Salud y Protección Social (compilación normativa de la Superintendencia Nacional de Salud), 2024).
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Representative model, for educational purposes only.