What are the clinical indications for referring a patient from primary care to an Ear, Nose, and Throat (ENT) specialist?

Clinical Indications for ENT Referral from Primary Care

Primary care clinicians should refer patients to ENT specialists for persistent symptoms beyond specific timeframes, red flag features suggesting malignancy, failed conservative management, or when specialized laryngeal/audiologic evaluation is required for accurate diagnosis and treatment.

Otologic (Ear) Indications

Otitis Media with Effusion (OME)

• Refer when OME persists beyond 3 months with hearing loss or structural abnormalities of the tympanic membrane or middle ear are suspected 1
• Refer children with OME who fail primary care hearing testing, are younger than 4 years, or cannot be tested in primary care settings 1
• Refer when adequate visualization of the tympanic membrane is impaired by cerumen and difficult to clean in the external ear canal 1
• Document effusion duration, laterality, hearing test results, suspected speech/language problems, history of acute otitis media, and developmental status when referring 1

Hearing Loss

• Refer patients with asymmetrical hearing loss or sudden sensorineural hearing loss (loss of 30 dB or more within 72 hours) urgently to otolaryngology 2
• Refer patients with conductive hearing loss or sensorineural hearing loss that does not improve with hearing aids to an otolaryngologist 2
• Refer to audiologists for comprehensive audiologic examination when patients fail primary care hearing testing 1

Vertigo and Vestibular Disorders

• Refer patients presenting with vertigo for face-to-face ENT consultation in the first instance, as telephone consultations are inadequate for this population 3
• Refer for loss of hearing, vertigo, or vestibular neuropathy related to treatment in head and neck cancer survivors 1

Laryngologic (Throat/Voice) Indications

Hoarseness (Dysphonia)

• Refer patients with hoarseness persisting beyond 3-4 weeks for laryngeal visualization, as delayed referral beyond 3 months doubles healthcare costs and risks missing serious diagnoses including laryngeal cancer 1, 4, 5
• Refer immediately if red flag features are present: smokers, age >40, associated dysphagia, hemoptysis, neck mass, weight loss, or professional voice users with significant impairment 1, 4, 5
• Refer when hoarseness may be caused by serious underlying conditions that could shorten life span or significantly impair work/quality of life 1
• Do not obtain CT or MRI prior to laryngeal visualization, as imaging before laryngoscopy causes unnecessary expense, radiation exposure, and does not improve outcomes 1

Dysphagia and Throat Symptoms

• Refer head and neck cancer survivors with dysphagia, postprandial cough, unexplained weight loss, or pneumonia to speech-language pathologists for instrumental swallowing evaluation 1
• Refer all 2-week-wait throat symptom patients for face-to-face ENT consultation in the first instance 3
• Refer patients with suspected stricture to gastroenterologist or head/neck surgeon for esophageal dilation 1

Rhinologic (Nose/Sinus) Indications

Nasal and Sinus Symptoms

• Refer patients with persistent nasal obstruction or congestion that may indicate chronic adenoiditis requiring adenoidectomy 1
• Refer head and neck cancer survivors with persistent nasal obstruction, frequent nosebleeds, or unusual nasal discharge 1

Head and Neck Mass/Cancer Surveillance

Suspicious Lesions and Masses

• Refer patients with black tongue lesions to ENT for urgent evaluation and biopsy within 2 weeks, as lateral tongue is a high-risk site for malignancy 6
• Refer patients with non-homogeneous oral lesions, lateral tongue location, age >40 years, ulceration, induration, firmness on palpation, persistent lesions >2-3 weeks, or cervical lymphadenopathy within 2 weeks 6
• For neck or face lumps, obtain imaging first (before ENT referral) to improve patient flow and facilitate safe discharge 3

Head and Neck Cancer Survivors

• Refer immediately if signs/symptoms of recurrence are present: non-healing swelling in head/neck, red or white oral patches, persistent sore throat, foul oral odor, lumps/masses, difficulty breathing, double vision, numbness/weakness, ear or jaw pain, difficulty chewing/swallowing, blood in saliva, loose teeth, or unexplained weight loss 1

Documentation Requirements for Referral

When referring to ENT, always provide in writing 1:

• Duration of symptoms and specific reason for referral (evaluation vs. surgery)
• Laterality of disease (unilateral vs. bilateral)
• Results of prior hearing testing or tympanometry
• Suspected speech/language problems or developmental concerns
• Relevant medical history (smoking, alcohol use, immunosuppression)
• Patient/caregiver attitudes toward potential surgery
• General health status and comorbidities

Common Pitfalls to Avoid

• Do not prescribe antibiotics for isolated tympanic membrane redness without other signs of acute otitis media 1
• Do not perform imaging (CT/MRI) before laryngeal visualization in patients with voice complaints 1
• Do not delay referral beyond 3 months for persistent hoarseness, as this significantly increases costs and risks missing malignancy 1
• Do not rely on telephone consultations for vertigo patients or 2-week-wait throat symptoms—these require face-to-face evaluation 3
• Do not attempt prolonged watchful waiting of OME when regular surveillance is impossible or when developmental risk factors are present 1