عيادات الأنف والأذن والحنجرة

Routine

Urgent (<5 days)

Immediate (ER referral)

Recurrent otitis externa (≥3 in 12 months) despite appropriate therapy

Significant canal stenosis or obstruction preventing effective topical treatment.

Eczema, psoriasis, or dermatologic conditions of the ear canal complicating treatment and requiring specialist input.

Chronic otitis externa (>3 months duration) → needs ENT evaluation for underlying skin conditions or canal pathology

Persistent Otitis externa symptoms despite appropriate therapy

Granulation tissue in the ear canal or persistent otorrhea in diabetic or immunocompromised patients → concern for early malignant otitis externa (MOE).

Severe, unrelenting otalgia (pain) disproportionate to exam findings, especially in high-risk patients (e.g., elderly diabetics) → early ENT referral to assess for MOE.

Suspected malignant (necrotizing) otitis externa with cranial nerve involvement → facial paralysis, dysphagia, hoarseness → requires urgent hospitalization, IV antibiotics, imaging.

Signs of systemic toxicity → high fever, altered mental status, sepsis.

Routine

Urgent (<5 days)

Immediate (ER referral)

Refractory cerumen impaction after failed removal attempts in PHC, including irrigation, cerumenolytics, or manual removal with appropriate tools.

Patients with anatomical abnormalities of the ear canal (e.g., exostoses, severe canal stenosis) making safe removal difficult in PHC.

Recurrent symptomatic cerumen impaction requiring frequent manual removal beyond what PHC can safely provide.

Cerumen impaction in patients with surgically altered ears (e.g., mastoid cavity) needing ENT expertise

Persistent otorrhea or foul-smelling discharge after cerumen removal, suggesting possible secondary infection or perforation.

Severe pain during or after removal indicating canal injury or TM perforation.

Suspected sudden sensorineural hearing loss mistakenly attributed to cerumen, especially if hearing loss persists immediately after removal

Significant bleeding post-removal with ongoing hemodynamic instability or active arterial bleeding (rare but requires immediate care).

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent or recurrent vertigo not responsive to initial treatment (e.g., BPPV unresponsive to repositioning maneuvers).

Suspected Meniere’s disease, vestibular migraine, or other central/inner ear causes requiring ENT or neurology input.

Progressive hearing loss with vertigo, suggesting vestibular schwannoma (acoustic neuroma).

Multifactorial dizziness in elderly patients with falls or significant functional impairment → needs specialist evaluation for rehabilitation or further diagnostics.

New or worsening dizziness with concerning but non-acute neurological signs, such as diplopia, dysarthria, ataxia, or unilateral weakness.

Persistent imbalance increasing fall risk, especially in older adults.

Signs of stroke or posterior circulation TIA, including sudden vertigo with any of:

• Diplopia, dysarthria, dysphagia, weakness, or numbness.
• new severe headaches or neck pain → suggests possible cervical artery dissection or central pathology.
• Severe ataxia or inability to stand/walk unassisted.

Acute vestibular syndrome with red flags, e.g., vertical or direction-changing nystagmus, skew deviation, new hearing loss → possible central cause requiring urgent imaging.

Severe dehydration from protracted vomiting → risk of electrolyte imbalance and hemodynamic instability.

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent unilateral or bilateral hearing loss lasting >4 weeks without obvious reversible cause (e.g., wax, recent URI).

Asymmetric sensorineural hearing loss (confirmed on audiometry) → needs ENT evaluation for retrocochlear pathology (e.g., vestibular schwannoma).

Progressive hearing loss impacting communication or quality of life, especially in children (speech delay) or adults (functional decline).

Recurrent or chronic otitis media with hearing loss, requiring tympanostomy or further workup.

Sudden sensorineural hearing loss (SSNHL) → defined as rapid onset of hearing loss in one or both ears over <72 hours → needs treatment within 14 days for best outcomes (e.g., oral or intratympanic steroids).

Hearing loss with red flags, such as:

• Severe vertigo.
• Facial weakness.
• Persistent severe tinnitus → suggests inner ear or retrocochlear pathology.

Hearing loss with signs of central neurological involvement, e.g.:

Confusion, weakness, vision changes → possible stroke.

Acute hearing loss following head trauma, with or without CSF otorrhea → concern for temporal bone fracture.

Signs of meningitis after ear infection or surgery → fever, neck stiffness, altered mental status.

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent or severe symptoms unresponsive to optimal pharmacotherapy and environmental control measures for at least 3 months, including intranasal steroids and antihistamines.

Consideration of allergen-specific immunotherapy (allergy shots) for patients with confirmed allergic triggers and ongoing symptoms.

Diagnostic uncertainty, such as unilateral nasal symptoms, purulent drainage lasting >10 days, or features suggesting alternative diagnoses (e.g., nasal polyps, deviated septum).

Associated comorbidities → suspected asthma, recurrent sinusitis, or otitis media with effusion.

Severe nasal obstruction causing sleep-disordered breathing or suspected obstructive sleep apnea, particularly in children → ENT evaluation for adenotonsillar hypertrophy or nasal obstruction.

Signs of orbital or intracranial complications of sinusitis, including:

Proptosis, vision changes.

Ophthalmoplegia.

Altered mental status.

Anaphylaxis symptoms triggered by allergen exposure → facial swelling, difficulty breathing, hypotension.

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent nasal obstruction, mouth breathing, or hyponasal speech due to enlarged adenoids or tonsils.

Suspected obstructive sleep apnea (OSA)

Recurrent tonsillitis meeting any of the following criteria:

• ≥7 episodes in the past year
• ≥5 episodes/year for 2 consecutive years
• ≥3 episodes/year for 3 consecutive years

Each episode should be documented and include fever, tonsillar exudates, cervical adenopathy, or positive group A strep test.

Chronic halitosis, dysphagia, or changes in voice related to tonsillar enlargement.

Persistent otitis media with effusion or recurrent acute otitis media associated with enlarged adenoids.

Failure to thrive or poor growth suspected to be related to sleep-disordered breathing

Airway obstruction signs: severe stridor at rest, significant retractions, cyanosis

Peritonsillar abscess or retropharyngeal abscess: drooling, trismus, muffled voice, unilateral swelling

Routine

Urgent (<5 days)

Immediate (ER referral)

Recurrent mild anterior epistaxis despite conservative measures (humidification, saline, simple cautery in PHC).

Suspicion of underlying cause needing ENT workup

Frequent epistaxis with anemia or requiring repeated packing.

Epistaxis in a patient on anticoagulation or bleeding disorder but currently controlled.

Profuse bleeding not controlled with anterior packing/pressure.

Posterior epistaxis (blood seen in oropharynx) → high risk airway compromise.

Hemodynamic instability (hypotension, tachycardia).

Routine

Urgent (<5 days)

Immediate (ER referral)

Symptoms >12 weeks despite maximal medical therapy (intranasal steroids + saline irrigation).

Nasal obstruction or anosmia affecting quality of life.

Suspicion of nasal polyps needing endoscopic assessment.

Unilateral persistent nasal obstruction ± purulent/bloody discharge (rule out tumor).

Recurrent acute sinusitis ≥4/year requiring repeated antibiotics.

Orbital or intracranial complications → proptosis, visual changes, ophthalmoplegia, altered mental status.

Urgent (<5 days)

Immediate (Referral to ER)

≥ 2 weeks duration despite treatment* OR associated with red flags, such as:

• Unexplained weight loss.
• Neck mass or lymphadenopathy.
• Dysphagia or odynophagia.
• Hemoptysis.

New-onset hoarseness in professional voice users (singers, teachers) with significant impact on function.

Hoarseness with stridor or signs of airway obstruction, e.g.:

• Severe respiratory distress.
• Audible high-pitched breathing.
• Rapidly worsening voice changes with swelling (e.g., angioedema, epiglottitis).

*Initial treatment: Voice rest, hydration, avoid irritants (e.g. smoking, dust, chemicals), limit throat clearing or coughing, and trial of PPI if GERD is suspected.

Routine

Urgent (<5 days)

Immediate (ER referral)

Persistent neck mass >2–3 weeks without infection history.

Suspicion of benign lesions (lipoma, branchial cleft cyst) needing excision.

Suspicious neck mass (firm, fixed, >2 cm, lasting >3 weeks) or associated with hoarseness, dysphagia, or otalgia (red flags for malignancy).

Asymmetric tonsillar enlargement or firm fixed cervical node.

Rapidly enlarging painful mass with airway compromise (e.g., Ludwig’s angina, peritonsillar or deep neck abscess).

Systemic toxicity (fever, sepsis signs).

Routine

Urgent (<5 days)

Immediate (ER referral)

Mild facial or nasal trauma without airway compromise or major deformity.

Benign-appearing oral lesions (e.g. mucocele) or small, painless neck swellings.

Stable chronic ear conditions (e.g., small dry perforation, long-standing otorrhea).

Chronic sialadenitis or salivary gland swelling without pain or systemic symptoms.

Unilateral nasal obstruction or persistent unilateral epistaxis (suspicious for tumor).

Facial nerve palsy with chronic ear infection (risk of cholesteatoma).

Persistent oral ulcers >2–3 weeks (rule out malignancy).

Progressive dysphagia (difficulty swallowing solids then liquids).

Airway compromise from any ENT cause (foreign body, tonsillar, epiglottitis, tongue, or laryngeal).

Foreign body in airway or with choking or respiratory distress.

Peritonsillar abscess (quinsy) with trismus & uvula deviation but no airway compromise.

Septal hematoma after nasal trauma (must drain within 48 h).

Deep neck infection (e.g. Ludwig’s angina, retropharyngeal abscess)