Dr. Naim Manhas 1

E.N.T. Emergencies in children

Dr. Naim Manhas. E.N.T. Specialist King Abdul Aziz Hospital

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Neonate

s

From birth to 28 days

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Choanal atresia

Neonatal emergencies

Neonates :-- from birth to 28 days Neonates are obligatory nasal breathers

during the first 3-5 months of life. Bilateral choanal atresia present at birth

with respiratory distress. Unilateral cases may present with

unilateral rhinorrhea or nasal obstruction.

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Bilateral Choanal atresia

Neonatal emergencies

Presentation :-

Cyclical cyanosis that improves with crying and worsens with feeding.

Failure to pass small catheter through choana is diagnostic

Sometimes it is associated with other congenital malformations , ( CHARGE )

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Bilateral Choanal Atresia

Bilateral Choanal Atresia in Neonate is treated on EMERGENT basis.

Airway is maintained by insertion of an oral Airway to break the seal formed by Tongue against the Palate. This oral Airway can be tolerated for several weeks.

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Bilateral Choanal Atresia The McGovern Nipple- with enlarged

hole through which neonate can breath as well as feed.

Intubation / tracheotomy.

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surgical correction

Previously it was known that Choanal atresia was 90% membranous and 10% bony so perforation was carried out transnasally under direct vision.

Stents are placed for 2-6 weeks o prevent re-stenosis.

50-85% success rates and failure results when choanae become obliterated by granulation tissue.

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surgical correction

Recent advances :- choanal atresia is composed of 29% of bony element and 71% of mixed membranous and bony elements.

The best modality is Laser therapy using carbon dioxide /YAG/KTP.

Less incidence of re-stenosis.

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infants

29 days to 1Year

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Infants Subglottc hemangioma / Airway

Infantile Hemangioma. Typically unilateral, can be

circumferential. Hemangiomas progress from an intial

Proliferative phase to Involutional phase.

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Sub-glottic hemangioma Proliferative phase starts soon after birth

and usually continues for 12 months, after which gradual involution ocurs over a period of years and resolve by the age of 5.

80-90% will present by the age of 6 months.

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Presentation

Lesion is small , inspiratory stridor is intermittently present.

Symptoms are excebratated by upper respiratory tract infection which may lead to initial diagnosis of Laryngotracheobronchitis.

Lesion enlarges, the stridor becomes biphasic and leads to dysnoea and cyanosis occur.

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Investigations Sagittal computed

tomography image with contrast :-

Showing contrast enhancing Airway Infantile Hemangioma in posterior glottis

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Investigations Confirmation of the

diagnosis is by Endoscopic Examination.

Typical finding :- Unilateral Sessile, submucosal compressible vascular lesion in the subglottis.

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Treatment

Goals of treatment :- Overcome the Airway obstruction Avoidance of long standing

complications like subglottic stenosis.

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Treatment

Medical therapy / Surgical therapy There are no standardized evaluation

protocols for Airway Infantile Hemangiomas , leading to broad variations in management.

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Medical therapy Steroids :- Intralesional and systemically Help in accelerating the involution of

hemangiomas ( mechanism of action is not known – hypothetically by Estrogen receptor blockade)

Systemically :- prolonged period growth retardation hypertension cushingoid syndrome

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Intra-Lesional injections Multiple injections

Local oedma

Airway compromise

Prolonged intubation

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Intra-Lesional injections Interferon :- Antiangiogenic activity in proliferative

phase Rebound effect Prolonged period can lead to

development of spastic diplegia

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surgical therapy

Laser therapy :- Carbon diaoxide and KTP ( potassium

titanyl phosphate) lasers are beneficial with only 25% incidence of subglottic stenosis.

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Surgical therapy

Open excision:- Previously was reserved for most severe

cases which did not respond to conventional method.

Development of single stage laryngotracheoplasty has become widely accepted because of less incidence of subglottic stenosis and avoidance of tracheotomy.

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Recent advances Introduction of non-selective B-blocker

Propanlol as effective in cutaneous hemangiomas . ( incidental findings in 2008)

Case reports:- Propanlol use in AIH has led to dramatic

reduction in lesion size and airway obstruction .

Dose:- 2-3 mg/Kg/day Side effects on cardiovascular and

respiratory systems.

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children

1 Year

to 12

Years

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Foreign Bodies Foreign bodies

ingestion is common in children.

They are mainly benign, in the absence of complications, do not represent surgical emergency except disc batteries.

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Disc -ion batteries LITHIUM ION DISC

BATTERY :- The incidence of

ingestion of these batteries has increased since the increase in household devices run on these batteries.

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Disc- ion batteries

Lithium ion disc battery generate a voltage even in discharged state which lead to rapid local injury, leakage of corrosive alkaline electrode results in hydrolysis of tissue and mucosal erosion.

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time of action

The window of opportunity for injury free removal of an esophageal battery is less than 2 hours.

Delay in removal will lead to complication ranging from local mucosal erosion to perforation.

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Inhaled Foreign Bodies Airway foreign bodies are

always managed on Emergent basis.

The initial symptoms and signs of laryngeal / Bronchial foreign body can be severe, including cyanosis, respiratory distress and even respiratory arrest.

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Investigation Radio opaque foreign body

is easily diagnosed on by radiology.

Other foreign bodies like peanut, vegetable seed which can not be visualized on X-Ray film, will present with localized atelectasis or infiltrate or by unilateral hyperinflation or by mediastinal shift.

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Partially occluding bronchial foreign body acts as a Ball-Valve causing hyper- expansion of the affected lung.

If Bronchial occlusion occurs, then total or partial lung collapse occur.

In children with chronic cough, wheezing who do not appear to respond to appropriate treatment, the presence of a foreign body should be suspected.

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Supraglottitis (epiglottitis) 2-6 years of age Rare infection,

awareness of the disease is important due to its high mortality if not promptly diagnosed and treated.

Rapidly progressive condition and usually caused by Haemophilius influnzae Type B

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Supraglottitis (epiglottitis) Start as URTI and within

hours the condition worsens. Severe odynophagia with

drooling of saliva. Child becomes irritable and

usually leans forward. Voice is muffled Later on inspiratory stridor

occurs.

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Diagnostic Tool Once supraglottitis is

suspected then further procedure should not be undertaken including intraoral examination as it will induce anxiety which can lead to complete airway obstruction.

Plain X-ray film of lateral neck is taken shows swollen epiglottis (Thumb Print)

Exclude foreign body and retropharyngeal abscess.

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Management

Examination of the child is done in O.R. where facility for intubation and tracheotomy is kept at hand.

Once the airway is secured by intubation then the investigations like blood culture, swab from supraglottis is obtained and I/V canula inserted.

Parental antibiotics is started

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Unresolving acute otitis media

Acute mastoiditis:- Failure of resolution of AOM Development of oedma and

erythema of post-auricular soft tissues with loss of post auricular crease.

Pinna gets displaced anterioinferiorly

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Mastoid Abscess If subperiosteal abscess

develops then fluctuation can be elicited.

Confirmation and assessment is done by Radiological C.T. scan.

Extent of the opacification of the mastoid air cells and development of any subperiosteal abscess is confirmed.

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Management

Acute mastoiditis without clinical and radiological indication of a subperiosteal abscess then high dose of parental antibiotics are given and child is monitored for 24 hours. In case of improvement then no surgical intervention is done.

If there is no evidence of resolution and symptoms progress then cortical mastoidectomy along with myringotomy is done .

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Management In case of clinically established case of

subperiosteal abscess , then surgery along with parental antibiotics become first line of treatment.

Subacute or Masked Mastoiditis occur when inadequate treatment of AOM is carried out. Child present with mild mastoiditis but persistent in course. These cases resolve by myringtomy with ventilation of middle ear and appropriate antibiotics.

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Thank you for your time.