"Pediatric ENT Emergencies" — Practice

Question 1

A toddler inhales a peanut into the right main bronchus. The expected early chest radiograph finding is

Accepted Answer

B

Question 2

Which feature best distinguishes epiglottitis from croup?

Accepted Answer

C

Question 3

A 3-year-old swallowed what the parents call 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?

Accepted Answer

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 view, distinguish a battery from a coin, and the parental history is not reliable.

This requires endoscopic removal immediately, targeted at within two hours of ingestion, because electrolysis generates hydroxide at the negative pole and produces liquefactive necrosis that begins within that window. While endoscopy is arranged, honey may be given since the child is over 12 months and the ingestion is under 12 hours, but it must not delay removal. Watch afterwards for stricture, tracheo-oesophageal fistula and aorto-oesophageal fistula.

Question 4

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 wish to go home. Advise.

Accepted Answer

He needs 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 therefore radiolucent, so the film can only demonstrate secondary effects.

The symptom-free interval after the initial choking episode is an expected part of the natural history and is falsely reassuring. A retained peanut swells, provokes intense inflammation and leads to recurrent pneumonia, bronchiectasis or lung abscess over subsequent months, and delayed removal is technically harder. Rigid bronchoscopy is preferred to flexible because it secures the airway while permitting instrumentation.

Question 5

A 2-year-old has a two-day history of barking cough and stridor at night, low fever, hoarse voice, no drooling, and is alert and feeding. Give the diagnosis and treatment.

Accepted Answer

Croup, that is laryngotracheobronchitis with subglottic oedema, usually caused by parainfluenza virus. The barking cough with hoarseness and the absence of drooling or toxicity separate it from epiglottitis.

Treatment is a single dose of oral dexamethasone, commonly 0.6 mg/kg, which benefits even mild disease and reduces return visits and admission. Nebulised adrenaline at around 400 micrograms per kilogram to a maximum of 5 mg is added if he deteriorates, but its effect appears by 30 minutes and wears off by about two hours, so any child who receives it is observed rather than discharged on the improvement.

Question 6

A 4-year-old with stridor has become quieter over 20 minutes. Respiratory rate has fallen from 50 to 28 and he is drowsy. The nurse reports he is settling. Comment.

Accepted Answer

He is not settling; he is failing. In a child who was previously distressed, quietening stridor with a falling respiratory rate means reduced air movement rather than reduced obstruction, and drowsiness indicates carbon dioxide retention and exhaustion.

The progression from agitation to drowsiness to a silent chest is the pre-arrest sequence. The correct response is immediate escalation to the most senior airway team available, with preparation for intubation and a surgical airway option, high-flow oxygen, and no attempt to examine the throat or reposition him in a way that could precipitate complete obstruction. Reassessing the diagnosis comes after the airway is secured.

Question 7

A newborn is cyanosed when quiet and pink when crying. A catheter cannot be passed through either nostril. Diagnosis and immediate management?

Accepted Answer

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 that is nearly diagnostic on its own.

The immediate management is to establish an oral airway, which bypasses the obstruction entirely, and to feed by tube until definitive repair. Confirm with CT of the skull base. Then look actively for CHARGE syndrome, since choanal atresia is one of its defining features, and search specifically for coloboma, heart defects, growth retardation, genital anomalies and ear abnormalities.

Question 8

A 4-year-old drank from a bottle containing drain cleaner. There are no visible oral burns and he is drinking normally. A colleague plans to send him home. Comment.

Accepted Answer

Discharge would be unsafe. The absence of oral burns does not exclude significant oesophageal injury, since the agent passes through the mouth quickly and does its damage where it dwells.

Drain cleaner is typically alkaline, and alkali causes liquefactive necrosis that penetrates deeply and continues acting after contact, so oesophageal injury can be severe and full thickness. Three actions must be avoided: inducing vomiting, which re-exposes the oesophagus; attempting neutralisation, which is exothermic and adds a thermal burn; and passing a blind nasogastric tube, which risks perforation. He needs admission and endoscopy within the first 24 to 48 hours to grade the injury, since grade predicts stricture formation, and strictures develop over weeks and may require repeated dilatation for years.

Question 9

A 6-year-old returns 7 days after tonsillectomy, pale and tachycardic, swallowing repeatedly. The oropharynx looks clean with some slough. What is happening and how does the timing guide management?

Accepted Answer

Secondary post-tonsillectomy haemorrhage. The timing of 5 to 10 days is characteristic and reflects infection of the tonsillar bed with separation of the slough, rather than a technical failure of haemostasis.

The clean-looking oropharynx is misleading because children swallow blood, which is why repeated swallowing, tachycardia and pallor are more reliable indicators of ongoing loss than anything visible. Management is admission, intravenous access, fluid resuscitation, cross-matching and intravenous antibiotics, since infection is the underlying cause, with return to theatre if bleeding is significant or continuing. This contrasts with primary haemorrhage within 24 hours, which reflects a bleeding vessel and almost always requires theatre.

Practice — "Pediatric ENT Emergencies"

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