When should I refer a patient to an ear‑nose‑throat (ENT) specialist?

When to Refer a Patient to ENT

Refer patients to ENT when symptoms persist beyond 3-4 weeks despite appropriate medical management, when complications develop, when structural abnormalities are suspected, or when red flag features are present that suggest serious pathology. 1

Immediate/Urgent ENT Referral

Refer immediately for any of the following red flag features:

Laryngologic Red Flags

• Hoarseness in smokers over age 40 1
• Associated dysphagia, hemoptysis, neck mass, or unexplained weight loss 1
• Professional voice users with significant vocal impairment 1

Rhinologic/Sinus Red Flags

• Periorbital edema, erythema, or displaced globe suggesting orbital involvement 2
• Visual changes including double vision, reduced acuity, or ophthalmoplegia 2
• Severe frontal headache with frontal swelling 2
• Neurological signs suggesting meningitis or intracranial extension 2
• Altered consciousness 2

Head and Neck Red Flags

• Non-healing swelling in head/neck region 1
• Red or white oral patches 1
• Persistent sore throat with foul oral odor 1
• Blood in saliva or unexplained loose teeth 1

Non-Urgent ENT Referral Indications

Otologic (Ear) Conditions

Refer for otitis media with effusion (OME) when:

• Effusion persists beyond 3 months with documented hearing loss 3, 1
• Structural abnormalities of tympanic membrane or middle ear are suspected 1
• Children under 4 years fail primary care hearing testing or cannot be tested 1
• Developmental risk factors are present (speech/language delay, cognitive impairment, cleft palate, autism spectrum disorder) 3
• Regular surveillance is impossible 3

Laryngologic (Voice/Throat) Conditions

Refer for hoarseness when:

• Symptoms persist beyond 3-4 weeks 1
• Do not delay referral beyond 3 months, as this doubles healthcare costs and risks missing laryngeal cancer 1
• Never obtain CT or MRI prior to laryngeal visualization—this causes unnecessary expense and radiation exposure without improving outcomes 1

Rhinologic (Nose/Sinus) Conditions

Refer for chronic rhinosinusitis when:

• Symptoms remain uncontrolled after 3-4 weeks of intranasal corticosteroids 2
• Recurrent acute rhinosinusitis occurs (≥3 episodes per year with complete resolution between episodes) 2
• Worsening symptoms after 48-72 hours of antibiotic therapy 2
• Nasal polyps persist despite medical therapy including oral corticosteroids 3, 2
• CT scan shows anatomical obstruction (septal deviation, ostiomeatal complex blockage) 2

Refer for chronic adenoiditis when:

• Persistent nasal obstruction suggests need for adenoidectomy 3, 1

Quality of Life Impact

Refer when the condition causes:

• Significant interference with work or school performance on chronic/recurrent basis 3, 2
• Sleep disturbance from symptoms 2
• Anosmia or ageusia affecting quality of life 2
• Requirement for systemic corticosteroids for symptom control 2

Complicating Comorbidities

Refer when associated with:

• Asthma (sinusitis worsens asthma control) 3, 2
• Chronic otitis media 3, 2
• Recurrent pneumonia or bronchiectasis 3, 2
• Aspirin sensitivity with nasal polyps 3, 2
• Suspected allergic fungal sinusitis 3, 2
• Immunocompromised status 2

Essential Documentation for Referral

Always provide in writing: 3, 1

• Duration of symptoms (how long fluid/symptoms have been present) 3, 1
• Laterality (unilateral vs bilateral involvement) 3, 1
• Specific reason for referral (evaluation vs surgery) 3, 1
• Results of prior hearing testing or tympanometry 3, 1
• Suspected speech/language problems or developmental concerns 3, 1
• History of acute otitis media 3
• Patient/caregiver attitudes toward potential surgery 3
• General health status and comorbidities (cardiac abnormalities, bleeding disorders, asthma, family history of malignant hyperthermia) 3
• Related conditions requiring concomitant surgery (nasal obstruction, obstructive sleep symptoms) 3

Consider Allergist-Immunologist Referral Instead

Refer to allergist-immunologist when: 3, 2

• Suspected allergic rhinitis requires IgE sensitization testing 2
• Suspected immunodeficiency (recurrent sinusitis plus otitis media, bronchitis, or pneumonia) 3, 2
• Need for immunologic assessment (quantitative immunoglobulins, functional antibody responses) 2
• Consideration of allergen immunotherapy 2

Common Pitfalls to Avoid

• Do not obtain CT or MRI before laryngeal visualization for voice complaints—this is wasteful and does not improve outcomes 1
• Do not delay hoarseness referral beyond 3 months—this significantly increases costs and risks missing malignancy 1
• Do not attempt prolonged watchful waiting of OME when regular surveillance is impossible or developmental risk factors exist 3, 1
• Do not prescribe antibiotics for isolated tympanic membrane redness without other signs of acute otitis media 1
• Ensure adequate medical management before referral: minimum 3-4 weeks of daily intranasal corticosteroids and high-volume saline irrigation (150ml daily) with proper technique 2