Background: Emergency otolaryngology services offer a vital lens to assess health system responsiveness, referral efficiency, and financial protection. The influence of pre-hospital delays, in-hospital processes, and out-of-pocket expenditure (OOPE) on ENT emergency outcomes remains underexplored in low- and middle-income settings. Methods: This prospective observational study enrolled 200 consecutively admitted ENT emergency patients at the Department of Otolaryngology—Head & Neck Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India (July 2021–December 2022). Patients were grouped as sinonasal (n=72, 36%), head and neck (n=55, 27.5%), deep neck abscess (n=50, 25%), otologic (n=15, 7.5%), and trauma (n=8, 4%). Data on pre-hospital pathways, referral causes, delay, door-to-intervention time, and OOPE were collected. Outcomes were assessed using Karnofsky Performance Status (KPS) and EQ-5D-5L at presentation, 1 week, and 3 weeks. Results: Mean age was 45.9 ± 17.3 years; 75.5% were male and 84.5% lacked insurance. Median pre-hospital delay was 6 days (IQR 3–13), with 1–2 prior facility visits. Referrals were mainly for deterioration (71.4%) or lack of operative infrastructure (18.6%). Door-to-intervention time varied significantly (p<0.001): longest in otologic (median 57 h) and shortest in trauma (median 7 h) cases. Pre-hospital delay was greatest in sinonasal conditions. Each additional delay day increased door-to-intervention time by 1.52 h and in-hospital expenditure by 286.11 units. Despite subsidised care, OOPE remained high for drugs, diagnostics, travel, and attendants. KPS improved from 54.2 to 85.3 and EQ-5D-5L from 55.0 to 84.7 (p<0.001). Conclusion: Referral delays, limited facility readiness, and weak financial protection constrain ENT emergency care. Strengthening district surgical capacity, enforcing time-bound referral targets, and expanding prepayment insurance are essential to improve timeliness, equity, and protection from OOPE.