Nasal problems, neck lumps, hoarseness and dysphagia

Airway and swallowing emergencies

Stridor, drooling, inability to swallow secretions, respiratory distress or a rapidly expanding neck swelling requires immediate airway-capable care. Consider deep neck infection, epiglottic disease, foreign body, anaphylaxis, post-operative haemorrhage and malignancy-related obstruction. Avoid upsetting a child with suspected severe upper-airway obstruction through repeated throat examination. Call senior airway/ENT support and arrange an appropriate setting. A normal oxygen saturation can persist until late obstruction and must not override the clinical warning signs.

Dysphagia should be separated into difficulty initiating swallowing and food sticking after the swallow. Coughing, choking or nasal regurgitation suggests oropharyngeal dysfunction, including neurological disease. Progressive solids-to-liquids difficulty raises mechanical oesophageal obstruction, while intermittent solids and liquids can suggest a motility disorder. Weight loss, anaemia, bleeding, odynophagia or persistent progression warrants timely investigation. An acutely obstructing food bolus with inability to handle saliva requires emergency endoscopic assessment; do not give oral fluids to “push it through.”

Epistaxis and nasal trauma

For a stable nosebleed, sit forward and apply firm continuous pressure to the soft part of the nose, allowing adequate time before release. Assess haemodynamics, anticoagulants, platelet disease and the bleeding site. Do not tilt the head back and encourage swallowing blood. Persistent, severe or posterior bleeding may need cautery, packing and ENT care, with monitoring for aspiration and haemodynamic compromise. Anticoagulant interruption/reversal depends on severity and thrombosis risk; it is not automatic for every minor nosebleed.

After nasal injury, look specifically for a septal haematoma, a soft swelling obstructing the septum, which needs urgent drainage assessment to prevent cartilage damage. A simple external deformity can be assessed through the appropriate fracture pathway, but a haematoma is not something to leave until swelling subsides. Clear rhinorrhoea after major head trauma raises CSF leakage and requires broader injury assessment. A child's unilateral foul discharge suggests a nasal foreign body. Button batteries require immediate specialist removal; blind repeated instrumentation or pushing the object deeper is unsafe.

Rhinitis and sinus symptoms

Allergic rhinitis often includes sneezing, itch and watery discharge. Trigger management, saline and appropriately used intranasal steroid can help; demonstrate technique and check adherence before escalating. Viral upper-respiratory illness is more common than bacterial sinusitis, so antibiotics are not routine for every coloured discharge. Persistent unilateral obstruction, bleeding or a mass requires structural evaluation. Facial pain without nasal symptoms can be migraine, dental disease or neuralgia rather than “sinus headache.” Assess the pattern rather than treating a diagnostic label inherited from an earlier visit.

Sinus disease with orbital swelling, impaired eye movements, reduced vision, severe frontal headache or neurological signs is potentially complicated and needs urgent imaging and ENT/ophthalmology input. Immunocompromised patients have additional risks, including invasive fungal disease. A routine outpatient antibiotic course is inadequate when intracranial or orbital extension is suspected. Explain warning signs to someone managed conservatively and arrange review for persistent or worsening symptoms. Avoid prolonged topical decongestant use that causes rebound congestion.

Neck lumps and voice changes

Describe a neck mass by duration, growth, location, tenderness, mobility and relation to swallowing. Ask about smoking, alcohol, infection, thyroid symptoms, weight loss and head/neck cancer symptoms. Persistent unexplained adult neck lumps merit prompt assessment; a cystic mass is not automatically a benign congenital cyst. Ultrasound, fine-needle sampling and ENT assessment are selected according to the suspected cause. Do not repeatedly give antibiotics to an unexplained persistent mass without a plan to establish the diagnosis.

Hoarseness commonly follows infection or vocal strain, but persistence, smoking history, haemoptysis, neck lump, dysphagia or breathing symptoms raises malignancy or vocal-cord dysfunction. Arrange laryngeal assessment rather than indefinitely prescribing reflux medicine without examination. Sudden hoarseness after laryngeal trauma or surgery may indicate airway injury or nerve dysfunction. A thyroid mass can affect voice and swallowing, and thyroid function can be normal in a structural cancer. Hyperthyroid biochemical testing does not replace structural assessment of a suspicious lump.

Clinical reasoning and continuity

A patient with uncomplicated short-duration rhinitis and no red flags can receive symptom advice and a review plan. A person with a persistent neck mass and new hoarseness needs prompt specialist investigation. A patient unable to swallow saliva after meat lodges needs emergency assessment, even if able to speak. Match the pathway to the functional danger and cancer risk rather than the discomfort score. Provide clear referral details and confirm escalation if access is delayed.

When dysphagia relates to neurological disease, coordinate speech pathology, dietetics, nursing and medical treatment. Texture modification must be individualised and reassessed; it does not eliminate all aspiration risk. Discuss nutrition, hydration and the person's goals, particularly in advanced disease. Feeding-tube decisions require capacity/consent and a realistic explanation of benefits and limits. Use supported communication when voice loss makes ordinary conversation difficult, and do not infer incapacity from an inability to speak loudly.

NSW ENT emergency criteria.

Review checkpoints

• Persistent hoarseness or an unexplained neck mass requires assessment.
• Stridor or drooling with distress can indicate a threatened airway.
• Posterior epistaxis or uncontrolled bleeding needs urgent senior treatment.