Abstract
Pediatric otorhinolaryngological emergencies constitute a major portion in emergency room presentations. The etiology of ENT problems in children is different from those in adults. Most of these can be managed conservatively while some need prompt management at a well equipped centre. To analyze the etiology, clinical profile and line of management of pediatric otorhinolaryngological emergencies. Retrospectively, records of 452 children up to the age of 16 years presenting with ENT complaints were included in the study. Out of 452 patients, 148 presented with aural complaints, 129 had nasal problems and 175 patients with throat complaints. They were classified into Trauma 69 (15.26%), Foreign body 278 (61.50%), Infective 82 (08.14%) and allergic/miscellaneous 23 (05.10%) cases. In aural complaints, foreign body insertion seen in 57 (12.17%) cases while earache in 55 (12.15%) patients. In patients with nasal complaints, foreign body was present in 78 (17.26%) cases. Nasal bleeding and discharge or pain and swelling around nose were the other presentations. Respiratory distress was present in 66 (14.60%) patients while 74 (16.37%) patients came with ingestion of some foreign body. Neck swellings were seen in 20 (04.42%) patients and 15 (03.31%) patients came with history of rashes, feeling of choking or allergic reactions. Surgical intervention after admission was the top most intervention in 202 (44.69%) patients followed by conservative management in 110 (24.33%) patients who were treated and then sent home from emergency centre itself. Minor surgical intervention was sufficient to treat 78 (17.25%) patients without admission. Most common ENT emergency was foreign bodies and these cases need operative intervention. Specialist ENT personnel is needed to handle these cases. Parents must be educated to keep likely causes of these foreign bodies out of reach of growing children and also need to be educated about signs like severe pain, dyspnoea, bleeding or unilateral nasal discharge for timely management.
Keywords: Foreign body, Conservative management, Infections, Trauma
Introduction
Emergency room services are an important part of any medical or surgical practice. An efficient emergency response is an indirect indicator of quality of health care services provided by a care centre to patients of that area. Otorhinolaryngological emergencies are common in all communities and their timely diagnosis and management is the key to reduction of mortality and morbidity [1]. Despite increasing specializations within the medical practice, most hospitals have a common emergency unit looked after by general medical officer who sorts out and initiate medical management of patients before the specialist steps in. Effective management requires correctly recognizing the patients on basis of seriousness and deciding which patients require conservative management and who needs subsequent admission and further management by a specialist [2].
The etiology of ENT emergencies varies according to age, area and socioeconomic status. Problems of ear nose and throat are an integral part of childhood. Children frequently suffer from diseases relating to ENT and pediatric population forms a major portion of patients turning up in emergency services [3]. Parents are very sensitive about the children therefore such pediatric issues need to be taken up with utmost care. The etiology of ENT problems in children is different from those in adults. Conditions like acute suppurative otitis media, acute tonsillitis [4] and foreign bodies [5] in aerodigestive tract are much more common in pediatric population. These are avoidable causes of morbidity and mortality which may sometimes rapidly progress to fatal outcome if not addressed in time. It has been found that most of these cases are not real emergencies. Most of these can be managed conservatively while some need prompt management at well equipped centre [3]. Managing an actual ENT emergency requires highly specialized equipments and personnel which may put a lot of financial burden on patient and if it’s not an actual emergency which needs to be dealt by a specialized person then it results in waste of precious time and manpower while putting pressure on already restrained medical services [2, 6–8].
There has been scarcity of literature on otorhinolaryngological emergencies in pediatric population. Aim of this study was to find out the etiological profile pattern and distribution of ENT emergencies in pediatric population reporting to emergency department of a tertiary care centre of North India. We also tried to get an insight into the actual cases where emergency treatment is required. This information will help in focusing on specific areas of training and sensitization of medical personnel who have first hand contact with such cases and channelization of resource which will eventually strengthen our health system and improve health services of the area.
Aim and Objectives
The study was undertaken to analyze the etiological and clinical profile, diagnosis and line of management of pediatric otorhinolaryngological emergencies presented to emergency department of a tertiary care centre of North India.
Materials and Method
This descriptive, retrospective study was conducted in a tertiary care teaching hospital in Northern India by analyzing data of emergency department of otorhinolaryngology. Study period was 2 years i.e. from June 2017 to June 2019. Clinical records of children up to the age of 16 years presenting to emergency department with complaint pertaining to ENT were included in the study. After due permission from the authorities, the information regarding age, sex, complaints, diagnosis and management were gathered from the records and entered into a proforma. Modified Cuchi’s etiological classification [9] was used. Collected data was tabulated, analyzed and statistically analyzed using SPSS software. Descriptive analysis was done and results were presented in tabular forms and charts.
Observations and Results
A total of 1672 emergencies came to ENT Emergency unit in the time period of study out of which 452 were pediatric emergencies. Out of total 452 patients, 350 were males and 102 females. The patient’s age ranged from 1 month to 15 years 7 months, the mean age being 6.34 ± 4.10 years. Out of 452 patients, 148 presented with aural complaints and 129 had nasal problems. 175 patients presented with complaints of throat and neck (Table 1).
Table 1.
Age and sex distribution
| Age in years | Male | Female | Total | % |
|---|---|---|---|---|
| 0–4 | 75 | 16 | 91 | 20.13 |
| 4–8 | 165 | 49 | 214 | 47.34 |
| 8–12 | 76 | 31 | 107 | 23.67 |
| 12–16 | 34 | 06 | 40 | 08.86 |
| Total | 350 | 102 | 452 | 100.00 |
In aural complaints, majority patients came with foreign body insertion in 57 (12.17%) cases and earache 55 (12.15%). Ear lacerations and bleeding from ear were other complaints encountered. In patients arriving with nasal complaints, history of insertion of foreign body was present in 78 (17.26%) cases. Nasal bleeding and discharge or pain and swelling around nose were the other prominent presentations. Respiratory distress was present in 66 (14.60%) patients upon arrival while 74 (16.37%) patients came with history of ingestion of some foreign body. Neck swellings were seen in 20 (04.42%) patients and 15 (03.31%) patients came with history of rashes, feeling of choking or allergic reactions (Table 2).
Table 2.
Presenting complaints
| Area | Complaint | Male | Female | Total | % |
|---|---|---|---|---|---|
| Ear | Earache | 40 | 15 | 55 | 12.15 |
| Foreign body | 43 | 14 | 57 | 12.17 | |
| Bleeding from ear | 12 | 06 | 18 | 03.98 | |
| Ear injury | 16 | 02 | 18 | 03.98 | |
| Nose | Nasal bleeding | 16 | 06 | 18 | 03.98 |
| Nasal laceration | 11 | 04 | 15 | 03.31 | |
| Pain/swelling | 14 | 04 | 18 | 03.98 | |
| Nasal foreign body | 54 | 20 | 78 | 17.26 | |
| Throat | Esophageal foreign body | 62 | 12 | 74 | 16.37 |
| Neck swelling | 18 | 02 | 20 | 04.42 | |
| Respiratory distress | 55 | 11 | 66 | 14.60 | |
| Others | 09 | 06 | 15 | 03.31 | |
| 350 | 102 | 452 | 100.00 |
After reviewing the patient data, filling the proforma and analyzing, the patients were broadly classified into cases of Trauma 69 (15.26%), Foreign body 278 (61.50%), Infective 82 (08.14%) and allergic/miscellaneous 23 (05.10%) cases. Few cases who presented with earache and bleed from nose and ear were found to be due to foreign bodies in nose and throat. Most of cases which presented with respiratory distress were due to foreign body in airway tract.
Foreign body nose was the most common reason 82 (18.14%) for a child to be brought to emergency department. Foreign body Oesophagus 74 (16.35%), Ear 73 (16.15%) and Airway 49 (10.84%) formed other major part of ENT emergencies. Acute suppurative otitis media (ASOM), Ear lacerations after Road traffic injuries, acute tonsillitis, Nasal soft tissue injury and epistaxis were the other reasons for emergency visits (Tables 3, 4).
Table 3.
Distribution of diagnosis according to symptoms
| Diagnosis group | EAR | Total (%) | Nose | Total (%) | Throat | Total (%) | Total (%) | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Male | Female | |||||
| Trauma | 22 | 07 | 29 (19.59) | 22 | 06 | 28 (22.48) | 08 | 04 | 12 (06.86) | 69 (15.26) |
| Foreign body | 56 | 17 | 73 (49.32) | 59 | 23 | 82 (63.57) | 101 | 22 | 123 (70.28) | 278 (61.50) |
| Infections | 24 | 11 | 35 (23.65) | 10 | 04 | 14 (10.85) | 29 | 04 | 33 (18.86) | 82 (08.14) |
| Allergic/other | 09 | 02 | 11 (07.44) | 04 | 01 | 04 (03.10) | 06 | 01 | 07 (04.00) | 23 (05.10) |
| Total | 111 | 37 | 148 (100.00) | 95 | 34 | 129 (100.00) | 144 | 31 | 175 (100.00) | 452 (100.00) |
Table 4.
Diagnosis of patients
| Diagnosis | 0–4 year | 4–8 year | 8–12 year | 12–16 year | Total (%) | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Male | Female | Male | Female | |||
| Asom | 2 | 1 | 5 | 4 | 3 | 2 | 2 | – | 19 | 04.26 |
| Otitis externa | 1 | – | 6 | 1 | 2 | 1 | 1 | – | 11 | 02.43 |
| Impacted wax | 3 | – | 1 | – | 4 | – | 1 | 2 | 11 | 02.43 |
| Otomycosis | – | – | – | – | 2 | – | 1 | 2 | 05 | 01.11 |
| Foreign body ear | 24 | 2 | 16 | 11 | 11 | 4 | 5 | – | 73 | 16.15 |
| Ear laceration | 1 | – | 3 | 1 | 6 | 2 | 12 | 4 | 29 | 06.41 |
| Epistaxis | 1 | – | 2 | – | – | – | 7 | – | 10 | 02.23 |
| Acute sinusitis | 1 | – | 2 | 1 | 3 | 2 | 1 | 1 | 11 | 02.43 |
| Nasal bone fracture | – | – | – | – | 2 | – | 5 | 2 | 09 | 01.99 |
| Nasal laceration | – | – | 2 | – | 3 | 1 | 6 | 3 | 15 | 03.32 |
| Nasal myiasis | – | 1 | – | – | 1 | – | – | – | 02 | 00.44 |
| Foreign body nose | 16 | 6 | 35 | 9 | 5 | 7 | – | 1 | 82 | 18.14 |
| Ludwig angina | – | – | – | – | 1 | – | 1 | – | 02 | 00.44 |
| Ac tonsilitis | 1 | – | 8 | – | 4 | 1 | 3 | 1 | 18 | 03.98 |
| Foreign body oesophagus | 12 | 5 | 30 | 5 | 14 | 2 | 6 | – | 74 | 16.35 |
| Foreign body airway | 9 | 7 | 18 | 3 | 10 | – | 2 | – | 49 | 10.84 |
| Paratonsilllar abscess | – | – | 2 | 2 | 2 | – | 7 | – | 13 | 02.86 |
| Maxillofacial trauma | – | – | 1 | – | 3 | 3 | 4 | 1 | 12 | 02.65 |
| Acute thyroiditis | – | – | – | – | – | – | 3 | 1 | 04 | 00.88 |
| Angioedema | 1 | – | – | – | – | – | 2 | – | 03 | 00.66 |
Foreign bodies were more common in 4–8 years of age followed by 0–4 years. Foreign bodies were uncommon in children older than 8 years. Maxillofacial trauma including nasal bone fractures and pinna lacerations were more common in children older than 12 years. Infective cases like paratonsillar cases, acute sinusitis, and impacted wax were more in children more than 8 years of age.
Surgical intervention after admission was the top most intervention in 202 (44.69%) patients followed by conservative management in 110 (24.33%) patients who were treated and then sent home from emergency centre itself. Admission followed by conservative management was done in 19 (04.22%) patients whereas minor surgical intervention was sufficient to treat 78 (17.25%) patients without admission and 43 (09.51%) patients after admission (Table 5).
Table 5.
Management received
| Management | No. of patients | Total | % | p Value | |
|---|---|---|---|---|---|
| Male | Female | ||||
| Conservative management without admission | 83 | 27 | 110 | 24.33 | 0.9275 (Fisher’s exact test for count data with simulated p value) |
| Conservative management with admission | 15 | 04 | 19 | 04.22 | |
| Minor surgical intervention without admission | 62 | 16 | 78 | 17.25 | |
| Minor surgical intervention with admission | 32 | 11 | 43 | 09.51 | |
| Major surgical intervention with admission | 158 | 44 | 202 | 44.69 | |
Discussion
Otorhinolaryngological emergencies in children are an unavoidable part of childhood growing experience. In our study there is a male preponderance similar to findings of Ibikwe [5], Taiwo et al. [2] and Farnerti et al. [10] whereas Kitcher et al. [1] reported in his study that females are more involved than males. In our study the most common age group involved was 4–8 years followed by 8–12 years which is in agreement with study done by Ibikwe [5] as children in this age are most curious and start to explore the surrounding and are therefore more vulnerable for infections, accidents and foreign body insertion. In a study conducted by Khan et al. [11], highest numbers of cases were seen in age group of 10–15 years with males presenting more than females. The sexual distribution of this study is in accordance to us whereas age distribution is in contradiction to our study.
In a study by Dutta et al. [3] nearly half patients presented with otological complaints and one-third with nasal complaints. Nasal foreign bodies were the most common problem along with earache. In their study Saha et al. [12] reported that throat cases were more common in their study. This was in agreement to our study. Foreign body was the most common cause of emergency presentations in our study with 278 (61.50%) patients presenting with foreign bodies. This is in accordance with study done by Ibikwe [5]. Similar results were published in a study by Kitcher et al. [1] in which foreign body esophagus; epistaxis and throat infections were the most common presentations. They observed that coins as foreign bodies were nearly 50% of all esophageal foreign bodies. However, our study is in contrast with work done by Perez et al. [13] and Timsit et al. [6] where commonest findings were epistaxis and peritonsillar abscess. In our study infections/Inflammations 82 (18.14%) were the second highest cause of emergency attendance with trauma following with 69 (15.26%) of patients. It is in accordance to study by Ferneti et al. [10]. Infection was reported as commonest cause in studies by Sanches Alcon et al. [14], Aremu et al [15] and Rossel et al. [16] where as it was reported as third commonest cause by Ibikwe [5] and Haunq et al. [17].
In our study, acute otitis media 19 (4.26%), otitis externa 11 (2.43%), acute tonsillitis 18 (3.98%) and sinusitis 11 (2.43%) were most common acute infective causes of presentations and were mostly managed conservatively without admission. Similar findings were noted by Ibikwe [5] in his study. Other forms of emergencies were neck injuries, acute tonsillitis, neck abscess, allergic angioedema and nasal myiasis. In a study by Bouchareb et al. [18] of 2220 pediatric ENT emergencies, Head neck wounds were 28.11%, foreign bodies accounted for 21.62%, infectious causes 21.57%, blunt trauma 16.39% and hemorrhages from nose ear and mouth was seen in 11.22% patients. The difference of causes of presentation is probably due to difference in socio economic structure and demography, most studies have been done in developed countries whereas ours is done in a low socioeconomic strata area of developing country. In our study maxillofacial fractures were seen in 29 (6.41%) cases whereas 12 (2.65%) patients presented with ear lacerations. Nasal soft tissue injury was seen in 15 (3.32%) patients.
The varied presentations require prompt diagnosis and immediate treatment. Dutta S et al. [3] concluded in their study that most of the patients who presented in emergency were easily managed by conservative treatment or simple procedures. This constituted 96.25% of the cases. Admission was necessary only in 2.75% patients. Similar findings were given by Al-Mazrou et al. [8] where 2.3% patients were admitted. Studies done by Taiwo et al. [2], Timsit et al. [6] and Malhotra [7] reported that only less than 10% cases of emergency cases require admission. However this is in sharp contrast to our study where 245 (54.20%) children were admitted for minor or major surgical intervention. This was mainly due to higher number of laryngopharyngeal foreign body presentations. Similar results were highlighted in a study done by Yojana et al. [19] who reported 75.7% admissions for ENT presentations. Lopez et al. [20] in their study observed that majority of admissions were for foreign body and respiratory distress.
Most of the nasal foreign bodies could be removed in emergency room without admission with help of foreign body hook or eustachian tube catheter. In most cases, removal of aural foreign bodies is not recommended in emergency without admission as the patient usually comes after self manipulation and so there are high chances of associated edema and injury of canal and tympanic membrane. In our study more than 80% of aural foreign bodies were removed after admission under anesthesia. Similar findings were reported by Mackle et al. [21] and Ibikwe [5].
The patients with acute airway obstruction or suspected foreign body ingestion were also managed surgically. Trauma to esophagus may occur during removal of foreign body as reported by Saha et al. [12] due to thinning of esophageal wall. Esophagoscopy and rigid bronchoscopy were commonly done under general anesthesia. Tracheostomy was done wherever required. In children of very young age, the foreign bodies of Hypopharynx and cricopharynx often present with airway obstruction. Airway and esophageal foreign bodies incidents can be prevented with proper parent awareness and supervision of children.
This study has its limitations in its retrospective nature causing incomplete records and loss of information. Also as it’s a single hospital study, it may be biased with the type of emergencies encountered and may not represent a larger picture of country.
Conclusion
Otorhinolaryngological emergencies in pediatric age group are not uncommon. Even though the mortality is low but there are chances of complications if they are not attended timely. The emergencies presented in childhood are much different from that of adulthood and so sometimes correct diagnosis of such cases is delayed. Most common ENT emergency are foreign bodies and as these cases would need operative intervention therefore there is need of specialist ENT personnel to handle these cases especially foreign bodies of ear and aerodigestive tract. Parents must be educated to keep likely causes of these foreign bodies out of reach of growing children and also need to be educated about danger signs like severe pain, dyspnoea, bleeding or unilateral nasal discharge so that these cases are not overlooked. Timely intervention is seen to drastically reduce the morbidity and mortality in such cases.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest. No funding was received for this project from any person or institution.
Footnotes
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