Nontraumatic Otorhinolaryngological Presentations in Gaza: Implications for Humanitarian Response in Armed Conflict Zones

Humanitarian relief and emergency response contexts can often dominate the discussion around otorhinolaryngology services and needs in Gaza, with focuses on blast injuries, airway-related burns, and oral-maxilliofacial trauma.^{1 -3} Yet alongside acute trauma cases, Palestinian clinicians are managing severe nontraumatic ENT cases, at times with diseases that are hard to detect and less survivable when routine pathways for in-patient hospital care are unavailable.^4,5 There are 2 issues of particular concern. Presentations that are suggestive of potential acute invasive fungal rhinosinusitis, including the possibility of rhino-orbital-cerebral involvement, as well as advanced tonsillar or oropharyngeal malignancy presenting late in the course of the disease. These are conditions in which the shift from hours to days can reshape prognosis, and in which delays in pathology, imaging, referral, or appropriate therapy can turn lethal. A central argument of this perspective is that armed conflict has not only increased the burden of traumatic ENT-related injuries but that there also exists a somewhat neglected tier of nontraumatic ENT emergencies that humanitarian frameworks and triages may overlook or fail to recognize.

While diseases such as mucormycosis are quite uncommon in the population, they can rapidly progress and be lethal in vulnerable individuals, particularly those with diabetes, diabetic ketoacidosis, neutropenia, hematologic malignancy, or severe immune dysfunction. ⁶ Early clinical suspicion coupled with immediate mapping of the disease, antifungal therapy when appropriate, and surgical debridement when possible is often necessary. ⁷ Invasive fungal rhinosinusitis is also a potential concern, as optimal care can at times depend on there being a coordinated clinical examination, nasal endoscopy, biopsy, histopathology, fungal studies, and imaging capable of defining orbital and skull-base extension. ⁸ These are often unavailable in the occupied Palestinian territories due to resource shortages, destruction of healthcare infrastructure, or blockade of essential medical supplies. ⁹ While CT scans and MRIs can sometimes be obtained, they are still somewhat limited in establishing pathology with confidence. Under these constraints, clinicians are often forced into a high-stakes, probability-based approach in treating patients whose presentations are strongly suggestive of a certain condition or invasive fungal disease while acknowledging residual diagnostic uncertainty.

During periods of severe food insecurity and medicine shortages in Gaza, many patients reduced or discontinued insulin and other antidiabetic therapies because of reduced caloric intake, interrupted primary care access, and inconsistent medication supply. Although some short-term laboratory values (eg, HbA1c) may have appeared somewhat acceptable in this phase, these findings can mask poor long-term glycemic control. As dietary patterns and weight normalize, inadequate re-initiation of chronic disease management may further increase susceptibility to severe infectious complications.

Another area of concern is nontraumatic upper aerodigestive malignancy, particularly the possibility of advanced tonsillar and oropharyngeal squamous carcinoma. Delayed review by a specialist, delayed histopathology, limited immunohistochemistry, and limited options for radiotherapy compound the issue. Barriers to obtain referrals or permits to obtain treatment abroad can also exacerbate the issue, as has been recorded for patients with cancer in Gaza.^{10 -12} For example, data on referrals in 2021 showcased that 25% of children with cancer waited over a month for permits, with 8% even dying while waiting for exit permits to leave Gaza. ¹² This means that tumors first seen as potentially curable may progress through weeks of system delay into unresectable, function-threatening, or metastatic disease, while patients simultaneously could be experiencing escalating dysphagia, pain, airway risk, and profound psychological distress.

The implications of this for health policy are that nontraumatic ENT disease in armed conflict zones should also be considered in humanitarian responses, even in terms of the equipment international healthcare workers bring with themselves. Emergency response can include amphotericin, related antifungals, and pathology support as part and parcel of the way they approach a given situation. A clinical framework may also benefit from considering support for pathways that can facilitate urgent and necessary evacuations, as well as general access to hospitals and medical supplies for patients and providers.