ENT surgery basics

• ENT surgery is a set of short, mostly day-case operations: tonsillectomy and adenoidectomy in children, functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis, excision of neck cysts and neck lump work-up, cancer diagnosis and referral, tracheostomy, and surgery to improve hearing.
• Much of the content is safety-critical and adult-versus-child differs (tonsillectomy and sinus surgery are mainly adult rules; congenital neck cysts are mainly paediatric; cancer referral thresholds depend on age).
• The golden rules repeated throughout this page: a neck mass in an adult is malignant until proven otherwise; congenital neck cysts are treated by complete excision; tracheostomy tube changes and decannulation are dangerous if done by the inexperienced; sudden hearing loss is an emergency.
• Use the current guidelines for the condition. This page names the edition it follows: the 2019 AAO-HNS tonsillectomy CPG update^[1], NICE NG12 (suspected cancer, last updated 15 April 2026)^[2], the 2017 AAO-HNS neck mass CPG^[3], the 2015 AAO-HNS adult sinusitis CPG update^[4], NICE NG98 (hearing loss, last updated 02 October 2023)^[5] and ENT UK's sudden sensorineural hearing loss guidance^[6].

By the end of this page you should be able to:

1. List the current indications and contraindications for tonsillectomy and adenoidectomy in children.
2. Describe when functional endoscopic sinus surgery is used, what must be confirmed beforehand, and the perioperative antibiotics and imaging rules for sinusitis.
3. Work through the evaluation of an adult neck lump: infection versus neoplasm, cystic versus solid, and the red-flag pathway.
4. Explain thyroglossal and branchial cyst origins, why the Sistrunk operation removes the central hyoid, and why complete excision matters. ^[8]
5. Recognise head and neck cancer red flags and the NICE NG12 suspected cancer referral thresholds.
6. Outline safe day-to-day tracheostomy care: humidification, stoma care, tube changes and decannulation.
7. Summarise the surgical options for hearing loss and which patients need urgent ENT referral.

Otolaryngology (ENT) surgery deals with the upper airway, the paranasal sinuses, the neck, the ear and the larynx. The subspecialty's topics overlap: a neck lump may be a congenital cyst, an infection or a cancer deposit; a sore throat in a child may be the entry point to tonsillectomy; a blocked nose may end in sinus surgery. This page gives the surgical basics common to all of them: indications, consent and preparation, operative principles and aftercare, plus the emergencies (tracheostomy, sudden hearing loss, airway malignancy). ^[3]

The reading assumes you know the regional anatomy of the neck, the tonsillar fossa and the sinonasal cavities, the airway and the inner ear. Work through the sections in order the first time, then use them as a reference at the bedside.

• Neck triangles and levels. The neck is divided into anterior and posterior triangles; lymph nodes are described by levels I to VI. A lateral neck mass lies in level II to V; a midline mass lies in the anterior midline. Midline versus lateral location decides whether a cyst is thyroglossal (midline) or branchial (lateral).
• Tonsillar fossa. Each palatine tonsil sits between the palatoglossal and palatopharyngeal arches. The tonsil is closely related to the superior constrictor muscle; dissection in the wrong plane bleeds.
• Paranasal sinuses and ostiomeatal complex. The frontal, anterior ethmoid and maxillary sinuses drain through the ostiomeatal complex. FESS opens these channels and improves mucociliary clearance.
• Larynx and trachea. The cricothyroid membrane is the emergency access point (cricothyroidotomy). Tracheostomy is usually placed between the second and fourth tracheal rings.
• Ear. The tympanic membrane separates outer and middle ear; the ossicular chain (malleus, incus, stapes) conducts sound; the cochlea and auditory nerve carry it centrally.

Tonsillectomy is complete removal of each palatine tonsil with its capsule, with or without adenoidectomy. It is among the commonest operations in children. It is mainly an operation in childhood (the guideline targets children aged 1 to 18 years)^[1]. Adult tonsillectomy exists for recurrent infection, peritonsillar abscess and cancer suspicion, but its indications are different.

Recurrent throat infection^[1]. Watchful waiting is recommended over tonsillectomy when there have been fewer than seven episodes in one year, five per year for two years or three per year for three years. Tonsillectomy may be offered when there have been seven episodes in one year, at least five per year for two years or at least three per year for three years, with medical-record documentation of each episode and at least one of: temperature over 101 degrees Fahrenheit (38.3 degrees Celsius), cervical adenopathy, tonsillar exudate, or a positive group A beta-haemolytic streptococcus test. Modifying factors that may make tonsillectomy worthwhile even below these thresholds include multiple antibiotic allergy or intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis) and more than one peritonsillar abscess.

Obstructive sleep-disordered breathing (SDB). In children with SDB and tonsillar hypertrophy, ask about comorbidities that improve after surgery: growth retardation, poor school performance, enuresis, asthma and behavioural problems. Children with obstructive sleep apnoea documented by overnight polysomnography should be referred for tonsillectomy. Polysomnography is recommended in children with SDB if they are younger than 2 years, or have obesity, Down syndrome, craniofacial abnormality, neuromuscular disorder, sickle cell disease or mucopolysaccharidoses. Where the need for surgery is uncertain, polysomnography should precede surgery. ^[1]

A single intraoperative dose of intravenous dexamethasone is strongly recommended. Pain relief is ibuprofen, paracetamol (acetaminophen) or both; potent opioids and codeine should not be used^[1]. Perioperative antibiotics should not be prescribed without another indication^[1]. Children under 3 years or with severe obstructive sleep apnoea need inpatient monitoring after surgery^[1].

Counselling should cover pain control at home, the risk of secondary haemorrhage at days 5 to 10, and that SDB can persist or recur after surgery. Surgeons should follow up patients and document primary (within 24 hours) and secondary (after 24 hours) postoperative bleeding rates at least annually^[1].

Tonsillectomy is performed under general anaesthesia, by cold steel, electrocautery or intracapsular (microdebrider) technique, completing haemostasis. Adenoidectomy removes the pharyngeal tonsil in children with nasal obstruction or middle-ear effusion. Known complications are primary and secondary haemorrhage, pain, dehydration and, rarely, velopharyngeal insufficiency. The published guidance warns that recovery is not complete until the fossae are epithelialised at 2 to 3 weeks.

Functional endoscopic sinus surgery (FESS) treats chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) that is refractory to medical therapy. It enlarges the natural ostia of the paranasal sinuses, removes obstructing bone, polyps or diseased mucosa where needed, and restores mucociliary drainage. It is not first-line for acute infection.

Chronic rhinosinusitis is a clinical diagnosis: nasal obstruction or congestion, anterior or posterior nasal discharge, facial pain or pressure, or reduced smell on most days. The guideline requires objective confirmation with anterior rhinoscopy, nasal endoscopy or computed tomography (CT) of the sinuses before the diagnosis is made^[4]. CT of the paranasal sinuses should be obtained when endoscopic sinus surgery is considered or planned, because it provides the anatomic detail that guides the procedure^[4]. Modifying conditions such as asthma, cystic fibrosis, immunocompromised state and ciliary dyskinesia should be sought, because they change management^[4].

The distinction between acute viral rhinosinusitis (AVRS) and acute bacterial rhinosinusitis (ABRS) drives management. ABRS is diagnosed when symptoms or signs of acute rhinosinusitis (purulent nasal drainage with nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or worsen within 10 days after an initial improvement (double worsening)^[4]. Radiographic imaging should not be obtained for patients who meet diagnostic criteria for acute rhinosinusitis unless a complication or alternative diagnosis is suspected^[4].

Initial management of uncomplicated ABRS is either watchful waiting or antibiotics; watchful waiting is only appropriate if there is assurance of follow-up, so that antibiotics can be started if the patient has not improved by 7 days after diagnosis, or worsens at any time^[4]. Where antibiotics are used, amoxicillin with or without clavulanate is the first-line agent for 5 to 10 days for most adults^[4]. Symptomatic relief for either AVRS or ABRS may be analgesics, topical intranasal corticosteroids and nasal saline irrigation^[4].

The standard initial procedure is uncinectomy and opening of the maxillary ostium, with extension to the ethmoids, frontal recess or (rarely) sphenoid as disease dictates. The same endoscopes and debriders are used for newer, less invasive variants such as balloon sinuplasty (dilating the natural ostia without removing tissue). FESS can improve asthma control, and endoscopically directed cultures of the middle meatus can guide antibiotics in difficult chronic cases. Asthma control should be assessed before surgery.

After surgery, debridement of crusts and mucus is performed by the operating team. Known complications include bleeding, cerebrospinal fluid leak from the skull base, orbital injury, synechiae and recurrence of disease. Discharge is usually the same day.

A neck mass is an abnormal lump in the neck, of any size. The 2017 AAO-HNS CPG is the only evidence-based guideline devoted to its evaluation^[3]. Its three aims are relevant to every student: reduce delay in head and neck cancer diagnosis, promote appropriate testing and reduce inappropriate testing.

Neck masses are common and adult masses often follow infection (ear, sinus, dental, streptococcal throat, mumps, goitre). An infected node usually resolves completely once the infection is gone; if the mass persists, reconsider. Most persistent neck masses in adults are neoplasms, and malignant neoplasms far exceed any other cause^[3]. A sensible working rule: in adults, a neck mass is malignant until proven otherwise, and late diagnosis worsens prognosis^[3].

Red-flag symptom list for an adult neck mass at high risk of cancer^[3]:

• The mass lasts longer than two to three weeks, or is growing. ^[3]
• The mass shrinks but does not completely go away.
• Voice changes, trouble or pain on swallowing, or trouble hearing or ear pain on the same side as the mass.
• Neck or throat pain.
• Unexplained weight loss.
• Fever above 101 degrees Fahrenheit (38.3 degrees Celsius).

Suspicious history (increased cancer risk): no history of infection, or the mass has been present for 2 weeks or more without significant fluctuation, or its duration is uncertain^[3]. Suspicious physical findings: fixation to adjacent tissues, firm consistency, size over 1.5 cm, or ulceration of overlying skin^[3]. Cystic masses need not be reassuring: HPV-related head and neck squamous cell carcinoma often presents as a cystic neck mass that is mistaken for a branchial cleft cyst, delaying diagnosis^[3].

Confirmed by the guideline: clinicians at increased risk should obtain a targeted examination of the mucosa of the larynx, base of tongue and pharynx; order CT or MRI of the neck with contrast; and perform fine-needle aspiration (FNA) rather than open biopsy if the diagnosis remains uncertain. Cystic masses must be followed until a diagnosis is made. Empirical antibiotics should not be prescribed without signs of bacterial infection. Examination under anaesthesia of the upper aerodigestive tract comes before open biopsy if FNA and imaging fail to give a diagnosis^[3].

Thyroglossal duct cyst. The commonest congenital neck mass. It arises from persistence of the thyroglossal duct, the tract along which the thyroid descends from the foramen caecum at the tongue base to its adult position. The cyst presents as a midline mass, usually near the hyoid bone, and characteristically moves up with swallowing and tongue protrusion. Treatment is the Sistrunk procedure: excision of the cyst, its tract, the midline portion of the hyoid bone and a cuff of base-of-tongue tissue, which reduces the recurrence rate. Simple excision without removing the central hyoid has a recurrence rate of 55.6%, versus 5.3% for the Sistrunk procedure^[7]. StatPearls quotes a recurrence of about 5% after Sistrunk versus a simple excision exceeding 50%^[8]. About 1% of thyroglossal cysts are malignant and are diagnosed only after excision^[8]. Infected cysts should be treated with antibiotics before surgery, and in rare cases where no normal thyroid tissue is present, thyroid replacement may be needed after removal^[8].

Branchial cleft cysts. Lateral neck cysts derived from incomplete involution of the cervical sinus of His. Branchial anomalies as a whole are the commonest paediatric congenital lesions of the head and neck, and the branchial cleft cyst is among the commonest (about 75% of branchial anomalies are cysts, the rest sinuses or fistulae)^[9]. Second branchial cleft cysts make up approximately 95% of all branchial anomalies, lying along or anterior to the sternocleidomastoid^[9]. First branchial cleft cysts account for about 7% of recorded cases; third and fourth branchial anomalies are rare (fourth make up 1 to 4% of all branchial cleft anomalies)^[9]. Definitive treatment is surgical excision, preferably after any active infection has been treated, often delayed until 2 to 3 years of age; complete excision, including the tract, is needed because incomplete removal leads to recurrence^[9].

NICE NG12 (last updated 15 April 2026) sets the referral thresholds for suspected cancer in primary care^[2]. Relevant sections for the head and neck:

Laryngeal cancer. Consider a suspected cancer pathway referral for people aged 45 and over with persistent and unexplained hoarseness, or an unexplained lump in the neck^[2].

Oral cancer. Consider a suspected cancer pathway referral for people with unexplained ulceration of the oral cavity lasting more than 3 weeks, or a persistent and unexplained lump in the neck. Urgent referral for assessment for possible oral cancer by a dentist is appropriate for a lump on the lip or in the oral cavity, or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia^[2].

Thyroid cancer. Consider a suspected cancer pathway referral for an unexplained thyroid lump^[2].

General principles from the same guideline that apply: persistent means present continuously or most of the time for more than 3 weeks, and unexplained means not readily attributable to a known condition. Suspected cancer pathway referrals aim for a diagnosis or ruling out of cancer within 28 days of referral. ^[2]

Head and neck squamous cell carcinoma is a common cancer; HPV-related oropharyngeal disease has increased in some populations and may account for a large proportion of cases, but incidence and trends should be checked against current local data. Cystic neck masses in young, non-smoking adults deserve particular vigilance for HPV-related disease.

Tracheostomy provides access to the lower airway, bypassing the upper airway; after a tracheostomy the patient is a "neck breather". It may be temporary or permanent (for example after laryngectomy). Daily meticulous care prevents the commonest complications: blockage and displacement. ^[10]

• Humidification is mandatory. Cold, dry air reaching the trachea bypasses the nose and causes thick secretions, crusting and obstruction. Use a heat and moisture exchanger (HME) ("Swedish nose") or heated water humidifier for every tracheostomy.
• Cuff management. Inflated (cuffed) tubes protect the airway and allow ventilation; never use a speaking valve with the cuff inflated; deflate the cuff for trials of speech or swallowing and for weaning; cuff pressure should be monitored to avoid tracheal mucosal ischaemia.
• Stoma and skin. Treat the stoma as a full-thickness open wound exposed to moisture and mucus. Keep tapes secure; always have two people present to change tapes to avoid accidental decannulation; observe for granulation tissue, which can bleed and obstruct tube changes.
• Inner cannula. Clean or replace disposable inner cannulas regularly; mucus plugging of the inner tube is a common cause of distress.
• Suctioning. Suction only when needed, with appropriate pressure and atraumatic technique, and pre-oxygenate.
• Tube changes. Tracheostomy tubes are usually changed about every 28 days, or when clinically indicated, and more often in the early postoperative period. The first change should be done or supervised by the team that inserted the tube; a surgically inserted tube does not necessarily need a surgeon subsequently, but the timing and circumstances should have been agreed at insertion. Tracheostomy tube changes must be by trained, competent staff. In an immature tract (less than 7 days old), an obese patient or one with a neck mass, the tract may collapse to a false passage, so an experienced operator, preferably a surgeon, should perform the change^[10].
• Stay sutures can be used to manipulate the trachea; the skin-to-tube ties can generally be removed at 5 to 7 days, after discussion with surgical or critical care staff^[10].

Early (first week): bleeding, misplacement, damage to head and neck structures, loss of the airway during manipulations, skin breakdown, infection. Late: displacement, blockage, bleeding, fistula, tracheal stenosis (presents weeks to months after decannulation from mucosal necrosis and scarring), tracheomalacia and granulomas. Displacement and blockage are the commonest complications^[10]. If the stoma is less than 7 days old, the tract is not mature and manipulation may create a false passage.

Weaning proceeds in stages: cuff deflation, fenestrated tube, speaking valve, capping trial, then removal. A decannulation cap is a solid cap that occludes the tube completely, so the patient must breathe through the upper airway; it is used only when the patient tolerates it. Decannulation should be performed as soon as is feasible to minimise risk, but risks include airway obstruction, aspiration, ventilatory failure and sputum retention; an occlusive dressing is applied to the stoma afterwards. The patient and team must know that a laryngectomy stoma is permanent: there is no connection to the upper airway, so these patients cannot be oxygenated or intubated through the mouth or nose. ^[10]

Hearing loss may be conductive (outer or middle ear), sensorineural (inner ear or nerve) or mixed. Surgery mainly restores conductive function or, when the inner ear fails, bypasses it with an implant.

• Myringoplasty or tympanoplasty closes a perforation of the tympanic membrane, improving hearing and preventing water entry.
• Ossiculoplasty reconstructs the ossicular chain, for example after chronic otitis media or cholesteatoma.
• Stapedectomy or stapedotomy removes or perforates the fixed stapes footplate and is the standard treatment for otosclerosis, giving air-bone gap closure in most patients.
• Mastoidectomy (cortical or modified radical) clears cholesteatoma disease from the mastoid and middle ear; hearing preservation is a secondary goal to disease control.

• Cochlear implantation is recommended (NICE TA566) for people with severe to profound deafness who do not receive adequate benefit from acoustic hearing aids: an electrode array in the cochlea stimulates the auditory nerve directly^[5].
• Bone-anchored hearing aids and middle-ear implants help selected mixed or single-sided losses.
• Auditory brainstem implant is used when the auditory nerve itself is absent, for example after neurofibromatosis type 2 surgery.

Sudden sensorineural hearing loss (SSNHL) is an ENT emergency. It is defined as hearing loss of 30 dB or more over at least three contiguous frequencies developing within 3 days^[5]. Most cases are unilateral, idiopathic in about 90% and present in adults in their 40s and 50s^[5]. NICE NG98 advises: if the loss developed suddenly within the past 30 days, refer immediately to be seen within 24 hours; if more than 30 days ago, or if it worsened rapidly over 4 to 90 days, refer urgently within 2 weeks^[5]. NICE recommends considering a steroid for idiopathic sudden sensorineural hearing loss in adults, and considering MRI of the internal auditory meati in adults with asymmetric sensorineural loss of 15 dB or more at any two adjacent test frequencies among 0.5, 1, 2, 4 and 8 kHz^[5]. ENT UK also defines SSNHL as an emergency and supports prompt ENT management^[6]. NICE separately recommends cochlear implants for severe to profound deafness^[5].

Some procedures are not an operation but a diagnostic step: fine-needle aspiration of a neck node, examination under anaesthesia with biopsy, and rigid (or flexible) endoscopy of the larynx and pharynx. These secure the diagnosis before definitive treatment (surgery, radiotherapy or systemic therapy) is decided by a multidisciplinary team.

• An adult neck mass is malignant until proven otherwise; 2 weeks or more of a lump without resolution, size over 1.5 cm, firm or fixed consistency, or any red flag needs imaging and FNA, not another course of antibiotics.
• ENT UK and the AAO-HNS CPGs and NICE NG12 set the red-flag thresholds for head and neck cancer; persistent hoarseness or a non-healing oral ulcer over 3 weeks in an adult, or an unexplained neck lump, earns a suspected cancer pathway referral.
• Tonsillectomy needs strict indications in children (7 in 1 year, or 5 per year for 2 years, or 3 per year for 3 years with documented episodes and qualifying features) plus polysomnography in high-risk groups; avoid perioperative antibiotics and codeine. ^[1]
• Treat chronic sinusitis only after objective confirmation; get CT before FESS; ABRS antibiotics only after 10 days or double worsening; amoxicillin with or without clavulanate for 5 to 10 days.
• Thyroglossal cysts are midline and need Sistrunk (recurrence about 5% versus about 56% with simple excision); branchial cysts are lateral and need complete excision.
• Tracheostomy care is high-risk: humidify always, never change a tube in the first week without experienced hands, change tapes with two people, observe for granulation, and assess fully before decannulation.
• Hearing loss surgery ranges from myringoplasty and stapedotomy to cochlear implantation; sudden sensorineural hearing loss is an emergency needing referral within 24 hours if under 30 days.

ENT preoperative assessment and airway management; chronic rhinosinusitis; head and neck cancer staging and treatment; salivary gland disease; thyroid and parathyroid surgery; otitis media and cholesteatoma; cochlear implantation; postoperative pain and wound care.