1. PEDIATRIC ENT EMERGENCIES
Greg Bell, MD
Department of Emergency Medicine

2. Key Points
Airway and esophageal foreign bodies complications can be avoided with suspicion and prompt treatment
Most nasal and ear FBs can be removed with some basic techniques, tools
Posterior pharynx trauma is scary but usually benign
Consider ultrasound for diagnosis of peritonsillar abscesses
Post-tonsillectomy bleeding needs close observation

3. What’s Concerning About Airway FBs?
About 3000 deaths/year - 2% of FB aspirations
33% are neither observed nor suspected
39% have a normal physical exam
20% have normal radiologic studies
The burden of proof of diagnosis lies in the physician hands

4. Who Is Affected By Airway FBs?
Children < 15, 1-3 years mostly
Globular objects usually – hot dogs, candies, nuts, grapes; also toys and balloons
Another good things about disposable diapers
Young kids because – lack molars, running or playing at the time of aspiration, put objects in their mouths, lack coordination of swallowing and glottis closure
3000 deaths per year

5. Where Do The FBs Go? Can settle at the larynx, trachea or bronchus
80-90% in the bronchus, right or left side in kids
The remaining 10-20% are larger and are divided between the larynx and trachea
80-90% bronchus
In adults, bronchial gbs tend to be lodged in the thr right mainstem
Equal right and left bronchial gb in kids
Larger objects end up in the larynx or trachea

6. 3 Clinical Phases…
Initial phase – choking and gasping, cough and gagging  “Penetration Syndrome”
Asymptomatic phase – lodging of object and relaxation of reflexes
Complication phase – FB produces local injury or obstruction
Coughing, or airway obst at the time of aspiration
Coughing choking and gagging and vocalizing have partial obstructionCessation of symptoms for hours to weeks
Leads to pneumonia, atelectasis or abscess

7. How Do They Present?
Tachypnea, tachycardia, chest retractions, decreased chest movements and wheeze most common
Laryngeal FB  airway obstruction, stridor, hoarseness or aphonia
Tracheal FB  similar symptoms though without hoarseness or aphonia. Possibly biphasic or expiratory wheezing
Bronchial FB  cough, unilateral wheezing and decreased breath sounds (classic triad)
Have to have clinical suspicion – sudden onset with playing or eating
Only in 2/3s
Foreign body aspiration can mimic other respiratory problems, such as asthma. Foreign body aspiration differs in the presence of unilateral wheezing and decreased breath sounds.

8. What Is Their Exam Like?
Wheezing, decreased breath sounds unilaterally - only present in 2/3 of bronchial FBs
Often absent findings when obstruction is partial

9. What About Airway Obstruction?
FBs that are round, large and expandable are concerning for complete obstruction
Partial obstruction more common
Consider the Heimlich maneuver for emergent obstruction
Patients without a serious airway concern have more time for decision making
Present with history of sudden symptoms without preceding illness
Often while playing or eating
Take to the OR if not able to remove

10. Imaging AP and lateral of neck for concerning laryngeal involvement
PA and lateral of chest for lower airway
May reveal obstructive emphysema or hyperinflation, atelectasis and consolidation, though are normal 13.5% of the time
Unilateral hyperinflation (64.9%), mediastinal shift (45.9%), and collapse (21.6%)
Trouble is that about 80% of aspirated FBs are organic (peanut in about ½)
Nirmal, et al. Polish J Otol, 2015

11. Imaging
Recent literature and professional opinion suggest that lateral decubitus and inspiratory and expiratory films are inaccurate – many false positives and negatives
Greater definition of the airway with reducing the effect of the surrounding bony structures
High rate of false positives
No benefit from expiratory films
Brown, et al. Ann Emerg Med, Jan, 2013

12. Imaging Multi-detector CT Radiolucent FBs in the tracheobronchial tree
Determines size, shape, location
In a pediatric series, identified 59/60 radiolucent FBs
PPV of 98%
The study found that in 59 out of 60 pediatric cases, rigid bronchoscopy confirmed MDCT-scan findings with regard to the presence of a vegetable foreign body, as well as the foreign body’s size, shape, and location, giving virtual bronchoscopy a positive predictive value of 98.3%. [3]
Behera, et al. J Laryngol Otol, Dec, 2014

13. Laryngoscopy Indicated for patients suspected of a laryngeal FB
Awake patient, topical anesthesia +/- mild sedation
Well tolerated
Able to remove supraglottic or laryngeal FB

14. Bronchoscopy Who gets it?
Witnessed FB aspiration
Radiographic evidence of FB
Classic symptoms (cough, unilateral wheeze with decreased breath sounds)
A strong history prompts an endoscopic evaluation, even without objective evidence
History and physical exam!
Chevalier Jackson
A strong history of suspected foreign body aspiration prompts an endoscopic evaluation, even if the clinical findings are not as conclusive or are not present.

15. Complications Most are a result of delayed diagnosis
2/3 of laryngotracheal FB complications occur when diagnosis is delayed 24 hours
Pneumonia and atelectasis are the most common, as bronchial involvement is most common
Bleeding can occur from granulation tissue surrounding the foreign body or erosion into a major vessel
Pneumothorax and pneumomediastinum from airway tears
Pneumonia and atel complications secondary to and after removal of bronchial foreign bodies.

16. What About Nasal FBs? Occur at 2-5 years of age
May present late- nasal discharge, congestion, recurrent bleeding
Food buttons, toys, erasers
Button batteries – as little as 7 hours

17. How To Remove? Positive pressure Mechanical extraction
Older kids who can ‘blow’
“Parent’s Kiss”
Mechanical extraction
Vasoconstrictor – Oxymetazonine, analgesic – 1% Lidocaine
?Sedation
Forceps
ENT for posterior positioning (concern for aspiration)
All positive pressure involve the risk of aspiration – so best for those that are mose anterior and can be visualized
Mechanical – more posterior, the more round, the greater the risk of spiration

19. Ear Foreign Bodies Irrigation works well
Euthanize insects before removal – Lidocaine or mineral oil work well
ENT for deep, hard to get hold of, painful
Spherical or sharp edged, disk batteries, vegetable matter

20. Penetrating Oral Injuries
Posterior pharynx
Lateral soft palate, tonsillar pillars?
Low risk of injury, lower of neurologic involvement
Series of 335 patients found 2 (0.6%) with injury to the ICA and none with neuro sequelae
Usually heal by secondary intention with antibiotics for large wounds
Soose, et al. Arch Otolaryngol Head Neck Surg, 2006

21. The Peritonsillar Abscess Dilemma
Abscess or phlegmon?
Blind needle aspiration, treatment of choice, sensitivity 78% and specificity 50% for abscess
False negative rate of 24%
CT diagnosis, sensitivity 100%, specificity 75% (considerable radiation risk to the thyroid)
Intra-oral Ultrasound (IOU), sensitivity 89-95%, specificity %
Secko, Am J Emerg Med, 2015

24. Uncomplicated Tonsillitis

25. Peritonsillar Abscess

26. What About Esophageal Foreign Bodies?
Usually radiopaque objects like coins, pins, screws, button batteries, toy parts
Alarming increase in magnet ingestion
Concerning complications including bleeding, scarring, obstruction and perforation

27. How Do They Present?
Most are lodged at the thoracic inlet, at the level of the clavicles, where skeletal muscle transitions to smooth
Concerning objects: >6cm long, 2cm wide, irregular, sharp, toxic
Esophageal FB symptoms: Dysphagia, food refusal, drooling and gagging, FB sensation, chest pain/sore throat, stridor, cough, and unexplained fever

28. The Surge of Magnet Ingestion
Alarming rate of magnet ingestion from 2002 – 2011, > 16,000 kids, which is a 8.5 fold increase
Concerning when more than one is ingested leading to pressure necrosis of intervening tissue  perforation
Abbas MI, et al. J Pediatr Gastroent Nutr, 2013

29. The Issue With Button Batteries
They too tend to lodge at thoracic inlet, depending on size
If localized to one place for more than 2.5 hours, they will begin to erode neighboring tissue, perforate in 6-8 hours
Clinically significant morbidity in 1.3% of ingestions
TE fistulas, esophageal perforation, esophageal stricture, vocal cord paralysis, tracheal stenosis

30. Post-Tonsillectomy Hemorrhage
Bleeding occurs in 2.5 – 7% and is commonly 5-10 days post-op
Patient with minor bleeding have a 40% rate of severe bleeding within 24 hours
Young children will often need general anesthesia, though Ketamine procedural sedation works well for older kids

31. Post-Tonsillectomy Hemorrhage
Bleeding occurs in 2.5 – 7% and is commonly 5-10 days post-op
Patient with minor bleeding have a 40% rate of severe bleeding within 24 hours
Young children will often need general anesthesia, though Ketamine procedural sedation works well for older kids

32. How To Manage Major Bleeding
Mobilize the troops
Manage the airway!
Patient needs to lean forward
Lots of light!
May need procedural sedation for young kids
Magill forceps and a LOT of gauze and suction
Evacuate clot and apply direct pressure on the tonsillar fossae
Adding Epinephrine 1:10,000 or Tranexamic acid to gauze helps
Push out laterally onto the tonsillar fossae

33. Thank you !

34. References
Abbas MI, et al. Magnet ingestions in children presenting to US emergency departments, J Pediatr Gastroenterol Nutr 2013; 57(1);
Behera G, et al. Role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree. J Laryngol Otol 2014; 128(12);
Brown JC, et al. The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies. Ann Emerg Med 2013; 61(1);
Fox S. Post-tonsillectomy Hemorrhage. Accessed April, 2017.
Nirmal SN, et al. Factors predicting early diagnosis of pediatric laryngotracheobronchial foreign bodies. Otolaryngol Pol 2015; 69(6):
Secko M and Sivitz A. Think ultrasound first for peritonsillar swelling. Am J Emerg Med 2015; 33(4);
Soose DJ, Simons JP, Mandell DL. Evaluation and management of pediatric oropharyngeal trauma. Arch Otolaryngol Head Neck Surg 2006; 132(4):
Stoner J and Dulaurier M. Pediatric ENT emergencies. Emer Med Clin N Am 2013; 31:
Walner DL. Emergency Medicine Procedures. McGraw Hill, 2004.