Pediatric ENT Emergencies
Paediatric ENT emergencies are not adult conditions occurring in smaller people. They behave differently because the anatomy and the physiology are different, and the difference is always in the same direction: less reserve.
Three facts generate almost every rule in this chapter.
The airway is absolutely small, and resistance rises with the fourth power of the radius. One millimetre of circumferential oedema in an infant trachea can raise resistance sixteen-fold. The same millimetre in an adult barely registers.
Oxygen reserve is minimal. Children consume oxygen at roughly twice the adult rate per kilogram while holding a proportionally smaller functional residual capacity, so the interval between apnoea and desaturation is measured in seconds.
Children do not report symptoms reliably. A toddler will not describe when something was swallowed, so the history comes from a parent who may not have seen the event, and the physical findings are often the only evidence.
The clinical consequence is that paediatric airway problems deteriorate abruptly rather than gradually, and that the calm-looking child is not necessarily the safe one.
1. Inhaled Foreign Body
Peak incidence is in toddlers, who explore with the mouth and lack molars to grind food. Peanuts, seeds and small toy parts dominate.
The classic history is a sudden choking or coughing episode, often followed by a symptom-free interval that falsely reassures everyone.
The right main bronchus is the commoner destination because it is wider, shorter and more vertical than the left, an anatomical asymmetry that becomes more marked with age.
Reading the chest radiograph
Most inhaled objects in children are organic and therefore radiolucent, so the film shows the effect rather than the object.
A foreign body acts as a ball valve: air enters past it on inspiration when the airway widens, and is trapped on expiration when the airway narrows. The result is hyperinflation of the affected side, not collapse, at least initially.
The findings are therefore a hyperlucent lung, a depressed hemidiaphragm and mediastinal shift away from the affected side, best seen on an expiratory film or a lateral decubitus view.
A normal chest radiograph does not exclude an inhaled foreign body. This is the single most important sentence in the section. A convincing choking history is an indication for rigid bronchoscopy regardless of the film, because the alternative is a child who develops recurrent pneumonia, bronchiectasis or lung abscess over the following months.
Rigid bronchoscopy under general anaesthesia is both diagnostic and therapeutic, and is preferred to flexible bronchoscopy because it secures the airway while permitting instrumentation.
The child who is choking now
A child with an effective cough is encouraged to cough and is not interfered with, because any intervention risks converting a partial obstruction into a complete one.
Once the cough becomes ineffective, the sequence differs by age. In an infant under one year, give five back blows followed by five chest thrusts, alternating; abdominal thrusts are avoided because the liver is relatively large and unprotected by the rib cage.
In a child over one year, give five back blows followed by five abdominal thrusts. If the child becomes unresponsive, begin cardiopulmonary resuscitation, checking the mouth for a visible object before each set of breaths but never sweeping blindly.
2. Swallowed Foreign Body
Most swallowed objects that reach the stomach pass uneventfully. The oesophagus is where they lodge, at three natural narrowings, of which the cricopharyngeus is the commonest.
A button battery in the oesophagus is a different order of emergency, and it is the highest-yield fact in this chapter.
The mechanism is not chemical leakage but electrolysis. Current flows through mucosa, generating hydroxide ions at the negative pole, and the resulting alkali produces liquefactive necrosis. Injury begins within two hours.
| Feature | Coin | Button battery |
|---|---|---|
| Radiograph, front | Uniform disc | Double ring or halo sign |
| Radiograph, lateral | Uniform edge | Step-off at the edge |
| Urgency | Remove if symptomatic or lodged | Remove immediately, ideally within 2 hours |
Removal takes priority over everything, and nothing should delay it. Current guidance permits honey, or sucralfate suspension, to be given while awaiting endoscopy in ingestions of up to 12 hours, since coating the battery slows local hydroxide generation. Honey is used in children aged 12 months and over.
Two caveats matter. Neither agent substitutes for removal; they slow damage rather than preventing it. And neither is given if the battery may have been present for more than 12 hours, or if perforation is suspected.
Late complications include oesophageal stricture, tracheo-oesophageal fistula and, catastrophically, aorto-oesophageal fistula, which can present with sentinel bleeding days after removal.
3. Foreign Bodies in the Nose and Ear
Unilateral foul-smelling nasal discharge in a child is a foreign body until proved otherwise. No other diagnosis explains one-sided purulent rhinorrhoea in a well child so reliably.
Nasal foreign bodies risk posterior displacement and inhalation, so removal is attempted only with adequate immobilisation and equipment.
A nasal button battery is an emergency for the same electrolytic reason as an oesophageal one, and it can destroy the septum within hours.
Aural foreign bodies are less urgent unless they are batteries, vegetable matter that swells, or a live insect, which is killed with oil before removal to prevent damage from movement.
4. Stridor in the Emergency Department
The critical initial task is grading severity, not diagnosing cause.
A falling respiratory rate with quietening stridor in a tiring child indicates impending arrest, not improvement. Reduced air movement produces less noise. Agitation, then drowsiness, then a silent chest is the sequence to fear.
| Condition | Age | Onset | Key features |
|---|---|---|---|
| Croup | 6 months to 3 years | Gradual, at night | Barking cough, hoarse voice, low fever, no drooling |
| Epiglottitis | 2 to 6 years, now rare | Rapid, hours | Toxic, drooling, muffled voice, sitting forward, no cough |
| Bacterial tracheitis | Any | Follows viral illness | Toxic child, thick purulent secretions, poor steroid response |
| Retropharyngeal abscess | Under 5 | Days | Neck stiffness, refusal to move neck, odynophagia |
| Inhaled foreign body | Toddler | Sudden | Choking history, unilateral signs |
Croup
Laryngotracheobronchitis, usually parainfluenza, producing subglottic oedema, which is why the stridor is often biphasic and the cough barking.
A single dose of oral dexamethasone is the treatment, and guidelines commonly use 0.6 mg/kg, with evidence for lower doses of 0.15 to 0.3 mg/kg being less clear-cut. It works even in mild disease and reduces return visits and admission.
Nebulised adrenaline, around 400 micrograms per kilogram to a maximum of 5 mg, is added in moderate to severe disease. It improves symptoms within 30 minutes but wears off after about two hours, so a child who has received it must be observed rather than discharged on the improvement.
Epiglottitis
Once a disease of Haemophilus influenzae type b, it became rare after Hib vaccination, with reported incidence in under-fives falling by more than 90 per cent. It has not disappeared, and now occurs in unvaccinated children, in vaccine failures, and with other organisms.
Do not examine the throat, do not lie the child flat, do not attempt cannulation. Keep the child upright with a parent, call the most senior anaesthetist and ENT surgeon available, and inspect and intubate in theatre with a surgical airway prepared. Antibiotics follow airway control.
Retropharyngeal abscess
Occurs in children under about five, because the retropharyngeal lymph nodes that drain the nasopharynx involute after that age.
The child holds the neck stiffly, refuses to swallow, and may be misdiagnosed as meningitis. A lateral neck radiograph shows widening of the prevertebral soft tissue, and contrast CT defines the collection.
The risks are airway obstruction and downward spread into the mediastinum, and treatment is intravenous antibiotics with drainage of a significant collection.
5. Tonsils, Quinsy and Bleeding
Acute tonsillitis is usually viral. The Centor criteria, comprising fever, tonsillar exudate, tender anterior cervical nodes and absence of cough, estimate the likelihood of streptococcal infection.
Peritonsillar abscess, or quinsy, is a disease of older children and adults, presenting with severe unilateral pain, trismus, a muffled "hot potato" voice and deviation of the uvula away from the swelling. Treatment is drainage by aspiration or incision plus antibiotics.
Never give ampicillin or amoxicillin when infectious mononucleosis is possible, since it produces a florid maculopapular rash.
Post-tonsillectomy haemorrhage
The division by timing is the examinable point.
Primary haemorrhage occurs within 24 hours and is a surgical problem, usually requiring return to theatre.
Secondary haemorrhage occurs at around 5 to 10 days, is caused by infection and separation of the slough, and is usually managed with antibiotics and observation, though a significant bleed still needs theatre.
Any child who has swallowed blood may have a deceptively empty mouth, so tachycardia, pallor and repeated swallowing are more reliable than visible bleeding.
Corrosive ingestion
Accidental swallowing of household acid or alkali remains common in India, where cleaning agents are often decanted into drink bottles.
The two agents injure differently. Alkali causes liquefactive necrosis that penetrates deeply and continues after contact, so oesophageal injury is severe. Acid causes coagulative necrosis, forming an eschar that limits depth, but it damages the stomach more.
Three interventions are actively harmful and are the examinable point. Do not induce vomiting, which re-exposes the oesophagus. Do not attempt neutralisation, which is exothermic and adds a thermal burn. Do not pass a blind nasogastric tube.
Absence of oral burns does not exclude significant oesophageal injury, so endoscopy within the first 24 to 48 hours grades the damage and predicts stricture. Strictures develop over weeks and may need repeated dilatation for years.
6. The Neonatal Airway
Choanal atresia presents dramatically because neonates are obligate nasal breathers. Bilateral atresia produces cyclical cyanosis relieved by crying, since crying forces mouth breathing.
The diagnosis is suggested by failure to pass a catheter through each nostril and confirmed by CT. An oral airway stabilises the child. It is associated with CHARGE syndrome, so a murmur or a coloboma should be sought.
Laryngomalacia is the commonest cause of stridor in infants. The stridor is inspiratory, worse on feeding, crying and lying supine, and better when prone. It appears in the first weeks, peaks around six months and usually resolves by 18 to 24 months.
Most cases need only reassurance and growth monitoring. Failure to thrive, apnoea or severe obstruction indicates supraglottoplasty.
Subglottic stenosis is most often acquired, following prolonged neonatal intubation, and gives biphasic stridor with recurrent "croup" that does not behave like croup.
7. Epistaxis and Acute Ear Pain
Nosebleed in a child
Almost all paediatric epistaxis arises from Little's area on the anterior septum, where five vessels anastomose in the Kiesselbach plexus, immediately beneath thin mucosa that a finger can reach.
First aid is anatomical: pinch the soft cartilaginous part of the nose, not the bony bridge, for ten uninterrupted minutes, with the child sitting forward so blood is not swallowed.
Recurrent bleeds respond to silver nitrate cautery of the visible vessel and topical antiseptic cream. Never cauterise both sides of the septum at the same sitting, since bilateral mucosal injury risks septal perforation.
Two features change the assessment entirely. Recurrent heavy epistaxis with nasal obstruction in an adolescent boy suggests juvenile nasopharyngeal angiofibroma, which must not be biopsied. And bleeding from multiple sites, or with bruising, points to a coagulopathy rather than a local cause.
Acute mastoiditis in a child
Untreated or partially treated acute otitis media can progress to mastoid empyema, and the child presents with a tender postauricular swelling, loss of the postauricular sulcus and a pinna pushed forward and downward.
It needs admission, intravenous antibiotics and often cortical mastoidectomy, and it can progress to the same intracranial complications as cholesteatoma.
8. Worked Examples
Example 1. An 18-month-old choked while eating peanuts three days ago. He is now well with a normal examination and a normal chest radiograph. The parents want to go home. What do you advise?
Rigid bronchoscopy. A convincing choking history is an indication for bronchoscopy regardless of a normal radiograph, because most paediatric inhaled foreign bodies are organic and radiolucent, so the film can only show secondary effects. The symptom-free interval after the initial choking is expected and falsely reassuring. Left in place, a peanut causes recurrent pneumonia, bronchiectasis or lung abscess over subsequent months, and organic material swells and provokes intense inflammation, making later removal harder.
Example 2. A 3-year-old swallowed "a coin" two hours ago. The radiograph shows a disc in the upper oesophagus with a double ring appearance. What is it and what happens now?
A button battery, not a coin. The double ring or halo sign on the frontal film, and a step-off at the edge on the lateral, distinguish a battery from a coin. This is an emergency requiring endoscopic removal immediately, ideally within two hours of ingestion, because electrolysis generates hydroxide at the negative pole and produces liquefactive necrosis that begins within that window.
While arranging endoscopy, honey may be given since he is over 12 months and the ingestion is under 12 hours, to coat the battery and slow hydroxide generation, but it must not delay removal by a minute. Watch afterwards for stricture, tracheo-oesophageal fistula and the catastrophic aorto-oesophageal fistula.
Example 3. A 2-year-old has had a barking cough and stridor at night for two days, with a low fever, a hoarse voice and no drooling. He is alert and feeding. What is the diagnosis and treatment?
Croup, from subglottic viral oedema, usually parainfluenza. The barking cough with hoarseness and the absence of drooling or toxicity separate it from epiglottitis, in which the child is toxic, drooling, has a muffled rather than hoarse voice and characteristically has no cough.
Treatment is a single dose of oral dexamethasone, commonly 0.6 mg/kg, which works even in mild disease and reduces return visits. Nebulised adrenaline is added if he deteriorates, but its effect wears off after about two hours, so a child given adrenaline is observed rather than discharged on the improvement.
Example 4. A 4-year-old with stridor has become quieter over the last 20 minutes. His respiratory rate has fallen from 50 to 28 and he is drowsy. The nurse reports he is settling. Comment.
He is not settling; he is failing. A falling respiratory rate with quietening stridor in a child who was previously distressed means reduced air movement rather than reduced obstruction, and drowsiness indicates hypercapnia and exhaustion.
This is the immediate pre-arrest state. The correct response is emergency escalation to the most senior airway team available, preparation for intubation with a surgical airway option, and no attempt to examine the throat or reposition the child in a way that might precipitate complete obstruction.
Example 5. A newborn becomes cyanosed when quiet and pink when crying. A catheter cannot be passed through either nostril. What is the diagnosis, and what is the immediate management?
Bilateral choanal atresia. Neonates are obligate nasal breathers, so complete posterior nasal obstruction causes cyanosis at rest, relieved when crying forces the mouth open, producing the characteristic cyclical pattern.
The immediate management is to establish an oral airway, which bypasses the obstruction entirely, and to feed by tube until definitive surgery. Confirm with CT of the skull base. Look actively for CHARGE syndrome associations, including coloboma, heart defects, growth retardation, genital and ear anomalies, since choanal atresia is one of its defining features.
Summary
Paediatric airways have almost no reserve: resistance rises with the fourth power of radius, and desaturation follows apnoea within seconds.
A convincing choking history mandates rigid bronchoscopy regardless of a normal chest radiograph.
Inhaled foreign bodies favour the right main bronchus and act as ball valves, causing hyperinflation rather than collapse.
Mediastinal shift is away from the affected side in the ball-valve phase.
A button battery in the oesophagus is removed immediately, ideally within two hours.
Battery injury is electrolytic, generating hydroxide and causing liquefactive necrosis.
The double ring sign on the frontal film distinguishes a battery from a coin.
Honey or sucralfate may be given within 12 hours while awaiting removal, but never instead of it.
Unilateral foul nasal discharge in a child means a foreign body.
Grade severity before diagnosing cause in a child with stridor.
A quietening stridor with a falling respiratory rate signals impending arrest.
Croup is treated with a single dose of dexamethasone, commonly 0.6 mg/kg.
Nebulised adrenaline works within 30 minutes and wears off by two hours, so observe.
Epiglottitis is now rare after Hib vaccination but has not disappeared.
Never examine the throat, lie flat or cannulate a child with suspected epiglottitis.
Retropharyngeal abscess occurs under five, before the retropharyngeal nodes involute.
Quinsy is a disease of older children and adults, with trismus and uvular deviation.
Avoid amoxicillin where mononucleosis is possible.
Primary post-tonsillectomy haemorrhage is within 24 hours; secondary is at 5 to 10 days from infection.
Bilateral choanal atresia gives cyclical cyanosis relieved by crying, treated initially with an oral airway.
Laryngomalacia is the commonest infant stridor and usually resolves by 18 to 24 months.
