ENT Emergencies: When to Go to the ER

The most dangerous ENT emergency is upper airway obstruction. It can be fatal within minutes; no waiting — call emergency services or rush to the ER.

Symptoms: 1) Stridor (a high-pitched obstructive sound, especially on inspiration), 2) Difficulty breathing — chest retractions, mouth-open effortful breathing, 3) Difficulty swallowing, drooling (especially in children), 4) Distorted speech — "hot potato voice", 5) Visible anxiety, tachycardia, sweating, 6) Blue lips or fingertips (cyanosis — late sign).

Common causes: epiglottitis (severe infectious swelling of the epiglottis — reduced by Hib vaccine but still occurs), anaphylaxis (allergic shock — laryngeal oedema), foreign body aspiration (especially 1-3 year olds), peritonsillar abscess (can push the larynx), caustic ingestion (accidental alkali or acid), acute obstruction by laryngeal tumour.

What NOT to do: insert a finger to remove the object (you can push it deeper), give water or food (aspiration risk). What to do: keep the person seated, calm, call ambulance. For a child not breathing: Heimlich manoeuvre (over 1 year) or infant back blows (under 1 year). We expand on the clinical framework in our general ENT services.

Nosebleeds affect 60% of adults at least once in their lifetime. Most are mild and stop spontaneously or with simple pressure. Some need urgent care.

Non-emergency (home-manageable): mild trickle, stops with 5-10 min pressure, after dry air or minor digital trauma. Treatment: sit, lean head slightly forward (not back — to avoid swallowing blood), pinch the soft tip of the nose firmly for 10-15 minutes, cold compress (wet cold cloth on forehead and nose). This works in 95%.

Emergency (to ER): 1) Bleeding not stopping after 40 min of pressure, 2) Heavy bleeding — flowing from mouth and nose, pallor or fainting, 3) Patient on blood thinners (Coumadin, Plavix, Eliquis etc.) — clotting impaired, 4) Recurrent bleeds (2-3 per week) — may indicate pathology (polyp, septal perforation, uncontrolled BP, tumour), 5) Post-traumatic — punch, road traffic accident — possible nasal bone fracture.

ER treatment: nasal endoscopy localises the source. Treatment: local vasoconstrictor (oxymetazoline), silver nitrate chemical cautery, electrocautery, balloon packing (Merocel or rapid rhino), in severe cases angio-embolisation. Hospitalisation usually not needed.

Sudden Sensorineural Hearing Loss (SSHL) is an ENT emergency: hearing loss developing within 24 hours, usually on one side. The typical story: "I woke up unable to hear from my right ear". 95% are unilateral.

Symptoms: sudden hearing loss, often with tinnitus, ear fullness, sometimes vertigo. Severity ranges from partial (some sounds lost) to total (no sound heard).

Cause is mostly unknown (idiopathic). Possible mechanisms: viral infection (cochlear viral inflammation), inner ear vascular issues, autoimmune, acoustic trauma, ototoxic drug. Rarely acoustic neuroma (vestibular nerve tumour) — hence MRI work-up.

Why emergency: early steroid treatment changes the outcome. If started within 72 hours of onset, 50-70% have partial or full recovery. Started after 1 week: 20-30%. After 2 weeks: <10%. Waiting "until tomorrow" is equivalent to lost hearing.

Treatment: systemic corticosteroid (oral prednisone or methylprednisolone) 7-14 days; sometimes intratympanic steroid (direct middle ear injection) added. Antihistamines or vestibular sedatives if vertigo. MRI to exclude acoustic neuroma (especially if no improvement at 6 weeks).

Foreign body is the commonest paediatric ENT emergency. Small objects placed in ear, nose, or throat. Rare in adults; peaks in children 2-5 (toy parts, beans, beads, small batteries, sticker bits, pencil tips).

Non-emergency (24-hour clinic): soft, atraumatic FB, no pain or bleeding. Home action: nothing. Trying finger or tweezers usually pushes deeper, may damage the eardrum. Don't shake or pour liquid into the ear (worse for a battery).

EMERGENCY (immediate ER): 1) Button battery — watch or hearing-aid type. Battery in nose or ear longer than 4 hours acts as chemical cauter; deep burn, septal perforation, even fatal progression. Don't wait if a battery is suspected. 2) Magnet — two magnets, one in nose, one external, pinch the mucosa between them; tissue death and perforation. 3) FB with bleeding or severe pain. 4) Airway FB — child choking, coughing, not breathing.

ER removal: ENT specialist visualises endoscopically and removes under microscope with specific instruments. Local anaesthesia in adults; short sedation may be needed in children (especially if previous attempts failed). Step-by-step details: ENT FAQ page.

Rapidly growing neck swelling (over hours-days) is usually infectious — deep neck abscess, peritonsillar abscess, submandibular abscess, parotid infection, Ludwig's angina (sublingual space infection — airway emergency).

Symptoms: swelling + warmth + redness + pain + fever. If swelling impairs breathing or swallowing it becomes a true emergency — possible airway compression. Voice change ("hot potato voice") is a dangerous sign that airway compromise is near.

ER work-up: fever, vital signs, CRP, blood count; neck CT (abscess in soft tissue plane, airway compression). Treatment: IV antibiotics (broad spectrum: amox-clav, clindamycin, cefepime), abscess drainage (surgical or CT-guided needle), airway monitoring. ICU admission in some cases.

Peritonsillar abscess — a specific and common form. Abscess in the tissue around one tonsil. Symptoms: severe one-sided sore throat, "hot potato voice", difficulty opening the mouth (trismus), drooling. Treatment: needle drainage or incision + IV antibiotics. Tonsillitis history with severe one-sided sore throat not improving on antibiotics in 3-4 days should be evaluated for peritonsillar abscess.

After facial or head trauma some ENT issues require urgent assessment. Most common: nasal bone fracture, septal haematoma, tympanic membrane perforation, CSF leak, blast/acoustic injury.

Nasal bone fracture: punch, ball impact, accident. Symptoms: deformity, pain, swelling, nasal bleeding, asymmetry. The first 24 hours of oedema mask the deformity; the true picture emerges at 5-7 days. Closed reduction must be done within 7-10 days — bones do not fully unite before then. After 2 weeks correction requires surgery.

Septal haematoma: blood collection between cartilage and mucosa of the septum. After trauma, both sides of the septum look swollen (like a blocked nose). If not drained within 24 hours, the cartilage dies and "saddle nose" deformity results. URGENT drainage needed.

CSF leak: clear watery fluid leaking from nose or ear after severe head trauma. Indicates intracranial fluid leaking out — meningitis risk. Urgent neurosurgery + ENT consult, imaging, CSF test. Conservative + surgical repair if leak does not close.

Blast/acoustic trauma: fireworks, gunfire, explosion proximity — eardrum rupture. Symptoms: sudden hearing loss, tinnitus, pain, bleeding. Most perforations heal spontaneously in 2-3 months; if not, surgical repair (tympanoplasty). Acute ENT evaluation essential. Related reading: our Istanbul ENT services.