|Year : 2021 | Volume
| Issue : 17 | Page : 47-52
Pediatric ear, nose, and throat emergencies: An experience from a tertiary center in Northwestern Nigeria
Mohammed Aminu Usman1, Iliyasu Yunusa Shuaibu1, Mohammed Ibrahim Babatunde1, Abdulrazak Ajiya2, Nurudeen Adebola Shofoluwe1, Dotiro Chitumu1
1 Department of Surgery, Division of Otorhinolaryngology, Faculty of Clinical Sciences, Ahmadu Bello University Zaria/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Otorhinolaryngology, Faculty of Clinical Sciences, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||02-Jun-2020|
|Date of Decision||11-Sep-2020|
|Date of Acceptance||21-Sep-2020|
|Date of Web Publication||24-Apr-2021|
Dr. Iliyasu Yunusa Shuaibu
Department of Surgery, Division of Otorhinolaryngology, Faculty of Clinical Sciences, Ahmadu Bello University Zaria/Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Background: Ear, nose, and throat (ENT) emergencies constitute a significant presentation at the pediatric emergency room worldwide. Often times, the management of these emergencies may be challenging, especially if the appropriate instruments/expertise are not available. Objectives: This study aims to present our experience in the management of pediatric ENT emergencies. Methodology: The record of pediatric patients managed for otorhinolaryngologic emergencies over 3 years between January 2015 and December 2017 was reviewed. Demographic and clinical data were retrieved and analyzed using the Statistical Product and Service Solution version 23.0 software (SPSS Inc., Chicago, Illinois, USA). Results: A total of 402 emergencies were reviewed. There were 206 (51.2%) boys and 196 (48.8%) girls with male-to-female sex ratio of 1.05:1 and mean age ± SD of 4.86 ± 3.9 years. Acute otitis media was the most common otologic pediatric emergency, accounting for 102 (25.4%). Ear foreign bodies (FBs) were the second most common otologic condition seen in 48 (11.9%) children. Nasal FBs were the most common pediatric nasal emergencies seen in 74 (18.4%) children. Obstructive adenoiditis was the most common throat condition in this study accounting for 37 (9.2%). There was a significant association between patient's ages and outcomes. Age < 5 years is a significant positive predictor of poor outcomes. Conclusion: Most of the emergencies are inflammatory diseases, followed by FBs of the ear, nose, and throat, and the majority of the cases can be managed on an outpatient basis. The provision of appropriate instruments and experts will greatly help in the successful management of such cases.
Keywords: Ear, nose, and throat, emergencies, pediatric
|How to cite this article:|
Usman MA, Shuaibu IY, Babatunde MI, Ajiya A, Shofoluwe NA, Chitumu D. Pediatric ear, nose, and throat emergencies: An experience from a tertiary center in Northwestern Nigeria. N Niger J Clin Res 2021;10:47-52
|How to cite this URL:|
Usman MA, Shuaibu IY, Babatunde MI, Ajiya A, Shofoluwe NA, Chitumu D. Pediatric ear, nose, and throat emergencies: An experience from a tertiary center in Northwestern Nigeria. N Niger J Clin Res [serial online] 2021 [cited 2022 Dec 9];10:47-52. Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/47/314596
| Introduction|| |
Ear, nose, and throat (ENT) emergencies constitute a significant presentation at the pediatric emergency room worldwide. An estimated 25%–40% of general medical practice relates to otorhinolaryngology diseases., ENT emergencies could be as a result of infections, trauma, hemorrhage, foreign body (FB) ingestion or inhalation, corrosive ingestion, and complications of some cultural practices like traditional uvulectomy. FB impactions are the most common pediatric otorhinolaryngologic emergencies.,, Often times, the management of these emergencies may be challenging, especially if the appropriate instruments/expertise are not available.
Prompt and appropriate intervention is, thus, necessary for tackling these emergencies to reduce morbidity and avoid possible mortality.
In the United States of America (USA), the pediatric age group accounted for 10%–40% of patients seen in the emergency department. In Sao Paulo, ENT emergencies constitute 52.2% of presentation at the pediatric emergency room. Another study reported that pediatric otorhinolaryngological emergencies constitute one-third of pediatric emergencies. Reports from North-central and Southern parts of Nigeria revealed the prevalence of pediatric otorhinolaryngologic emergencies to be 63.5% and 38.2%, respectively. However, in the Northwestern part of Nigeria, the review of the literature shows a paucity of reports on the prevalence of pediatric otorhinolaryngological emergencies. This study aims to present our experience in the management of pediatric ENT emergencies.
| Methodology|| |
This was a retrospective descriptive study of pediatric patients who presented with emergencies to the otorhinolaryngology clinic, accident and emergency, and pediatric emergency units of our hospital.
The records of pediatric patients managed for otorhinolaryngologic emergencies over 3 years between January 2015 and December 2017 was reviewed. Data obtained included demographic characteristics such as age, sex, diagnosis, clinical presentation, the treatment offered, and outcome.
Excluded from the study were patients whose case records were either not found or did not have complete information. The data were entered into the spreadsheet and analyzed using the Statistical Product and Service Solution version 23.0 software (SPSS Inc., Chicago, Illinois, USA). Quantitative data were summarized as frequencies and percentages and presented as tables. Statistical relationships were analyzed using the Chi-square test and multiple logistic regression analysis. P value was set at < 0.05.
| Results|| |
Of the 1340 children who presented with ENT diseases to our center within the period under review, 482 (36%) were emergencies. Of the 482 children, only 402 cases fulfilled the inclusion criteria having complete clinical records. There were 206 (51.2%) boys and 196 (48.8%) girls with male-to-female sex ratio of 1.05:1. Their ages ranged from 3 months to 15 years with a mean age ± SD of 4.86 ± 3.9 years. Children 0–4 years were observed to be the most common age group affected accounting for 269 (66.9%), followed by 5–9 years 73 (18.2%). Children more than 14 years of age were the least affected in this study [Table 1].
Otologic emergencies were the most common, seen in 217 (54.0%) patients, followed by nasal emergencies accounting for 107 (26.6%) patients. Throat emergencies were the least common, seen in 78 (19.4%) patients. Among all the emergencies in this study, acute otitis media (AOM) (suppurative and nonsuppurative) was the most common, accounting for 102 (25.4%) patients [Figure 1]. It also constituted 47.1% of all otologic-related emergencies [Table 2]. Most of them presented with otalgia/ear tugging, fever, and excessive cry with or without otorrhea. The patients were managed conservatively with antibiotics, analgesics, and decongestants.
|Figure 1: Distribution of otorhinolaryngologic emergencies among the study population|
Click here to view
|Table 2: Types of otologic emergencies among the study population (n=217)|
Click here to view
Ear FBs were the second most common otologic diseases seen in 48 (11.9%) children. The FBs were mainly beads, cotton buds, seeds, and erasers [Figure 1] and [Table 2]. Otitis externa was seen among 46 (11.5%) children. Otalgia, itching, and history of cleaning of the ear with an object by the child or the mother were the most common complaints at presentation. Steroid-based antibiotic ear drop, analgesic, and counseling were the treatment offered [Table 2].
External ear injuries were observed in 10 (2.5%) children and consisted of external auditory canal injury and pinner laceration. Injury caused by stick or pen and fall during play or fight were the mechanisms of external ear injuries in our patients. Other otologic-related emergencies were otalgia (5, 1.2%), traumatic tympanic membrane perforation (2, 0.5%), and vertigo (2, 0.5%) [Table 2] and [Figure 1].
Among the patients who presented with ENT emergencies, nasal FBs were seen in 74 (18.4%) children. It constituted 78% of all sinonasal emergencies [Table 3]. The FBs were removed using the Jobson Horne probe and Tilley's nasal dressing forceps in the clinic. Seventy-three (98.6%) of the FBs were removed in the clinic and only 1 (1.4%) was removed under general anesthesia. Epistaxis was observed in 24 (6.0%) children. It also comprised 22.4% of all sinonasal emergencies [Table 3]. Most of the children had a history of nose picking, fall from height, or fight with other children. Acute rhinosinusitis and nasal fracture observed in 8 (2.0%) and 1 (0.25%) patients respectively, were the least common nasal emergencies in this series.
Obstructive adenoiditis accounted for 37 (9.2%) children and constituted 47.4% of all throat emergencies [Table 4]. The children presented with symptoms such as rhinorrhea, noisy breathing, mouth breathing, and fever with no evidence of tonsillar infections. They were managed with antibiotics, analgesics, nasal decongestant, and steam inhalation. Acute tonsillitis was the second most common throat emergency seen in 15 (3.7%). Most of them presented with fever, odynophagia, dysphagia, and neck pain. They were managed with antibiotics and analgesics with or without rehydration.
Other throat emergencies observed in our study group included FB in the esophagus (15, 3.7%) and airway (11, 2.7%) [Figure 1] and [Table 4]. Esophageal FBs were removed through rigid esophagoscopy. Tracheostomy followed by bronchoscopy was offered to children with FBs in the trachea and bronchus. However, most of the laryngeal FBs were removed via direct laryngoscopy.
Three hundred and sixty-seven (91.3%) children who presented within the period under review were treated as an outpatient and did very well. Thirty (7.5%) of the children were admitted. Most of them were cases that required surgical interventions like FB in the esophagus and airway. Only 5 (1.2%) patients were referred elsewhere, mostly due to a lack of expertise/faulty instruments at the time of presentation [Figure 2].
|Figure 2: Outcome of treatment of patients who presented with otorhinolaryngologic emergencies|
Click here to view
Pearson's correlation analysis showed a significant association between patient's age and outcome of treatment in patients with ENT emergencies (Chi-Square = 5.444, P = 0.020) [Table 5].
|Table 5: Demographic factors affecting outcome among patients with ear, nose, and throat emergencies|
Click here to view
Multiple logistic regression analysis revealed age < 5 years to be a positive predictor of poor outcome among patients with ENT emergencies (odds ratio = 0.333, P = 0.026) [Table 6].
|Table 6: Determinants of outcome in patients with ear, nose, and throat emergencies|
Click here to view
| Discussion|| |
The management of otorhinolaryngological emergencies can be challenging, especially in the pediatric age group. This difficulty could be further compounded in resource-poor settings typical of most Sub-Saharan African countries.
In this study, the prevalence of pediatric ENT emergencies was 36%. This compares favorably with 27% reported by Rana et al. from India and 38.2% by Ibekwe. In sharp contrast to this, Adoga et al. reported prevalence of 63.5%. This may be due to the relatively smaller study population in their series. Children between 0 and 4 years were the most commonly affected in this study. This is also the findings of Adoga et al. from Nigeria. In contrast to this, Rana et al. from India reported the age group 4–8 years to be the most common. This may be due to increased incidence of recurrent upper respiratory tract infections among the under 5 age group. Moreover, curiosity and interest in exploring the natural orifices are common among the under 5 age group and hence are prone to insertion of FBs into the ear, nose, or throat. The preponderance of male sex in our study is in agreement with the findings of several other studies.,,, The male sex preponderance may be due to perceived hyperactive nature of boys which predisposes them to having trauma, including FBs.
Infections of the ENT were the most common reason for presentation in this study. Among this, we found AOM as the most common. A similar study by Nisar et al. and Sharma et al. from India also reported AOM as the most common infective condition occurring in 21.03% and 7.96% of their study population, respectively. In contrast to this, acute tonsillitis was reported as the most common otorhinolaryngologic emergency among children in Jos, Nigeria. A literature review showed that AOM is one of the most common otologic disorders affecting children necessitating presentation to the hospital. It is estimated that more than 80% of the pediatric population will experience at least one episode of AOM by age 3 years.
Recurrent upper respiratory tract infection couple with short, wide, and the more horizontal Eustachian tube More Detailss is the common predisposing factor for the development of AOM.
Among our patients who presented with FBs, the nasal cavity was the most common site. This was also the findings of Nisar et al. and Sharma et al. Contrasting finding was reported by Adoga et al. where the ear was the predominant site. Several studies have shown that FBs are the most common pediatric ENT emergency presentation.,, These FBs, especially in the ear and nose, may be inserted by the child, siblings, or other children in school or at home. FBs in the ear and nose can simply be removed in the clinic by restraining the child and the use of instruments such as Jobson Horne probe and crocodile and Tilley's nasal dressing forceps. However, removal under general anesthesia may be considered in uncooperating children. Although nasal and aural FBs were considered as less serious emergencies, their management by unskilled health-care personnel may lead to serious morbidity and rarely mortality. The least common FBs encountered in this study were those of the esophagus and airway. These were also the findings of other similar studies.,, However, Awad and ElTaher. reported swallowed FBs as the most common in their series. FBs in the esophagus or airway (larynx, trachea, and bronchus) are usually removed under general anesthesia by esophagoscopy and bronchoscopy/direct laryngoscopy, respectively. Because of the thinness of the esophageal wall, and the possibility of a fatal accident such as perforation, only a well-trained physician should perform esophagoscopy and FB removal. Furthermore, securing the airway through tracheostomy before FB removal may be very important in some cases of FBs in the airway.
Epistaxis in children is not uncommon, though usually not severe. Most cases resolve spontaneously and therefore can be managed at home or in the community clinic. Most of our patients with epistaxis had a preceding history of nose picking, fall, or fight before the onset of the epistaxis. Childhood epistaxis is usually associated with digital trauma. However, other causes such as allergic, viral, and bacterial rhinitis should always be ruled out. Literature search showed that most cases of epistaxis in children can be managed by applying digital pressure on the alar cartilage for 5–10 min, cauterization of the site if visible, or nasal packing with gauze soaked in vasoconstrictors. However, silver nitrate cauterization and nasal packing using liquid paraffin and gentamicin ointment impregnated gauze (usually for 48 h) or merocele (usually for 5–7 days) were the most common methods of managing epistaxis in our center. Subsequent use of antiseptic creams such as chlorhexidine hydrochloride 0.1% and neomycin sulfate 0.5%) has also been described in the literature. Other traumatic conditions including external ear injury (stick injury to external auditory canal and pinner laceration), tympanic membrane perforation, and nasal fractures were also observed. A similar study by Khan and Arif revealed that nasal fracture was the most common injury encountered in their series.
Majority of our patients were managed as outpatient. Contrasting findings by Adoga et al. showed that up to 78.2% of their cases were managed as an inpatient. This may be due to a large number of patients with pharyngotonsillitis which is usually associated with refusal of diet, fever, and dehydration. Most cases of AOM, otitis externa, and acute rhinosinusitis can be managed on an outpatient basis with satisfactory results. All patients who had surgical intervention like those with esophageal and airway FBs were admitted and subsequently discharged after removal. Few of our patients with FBs in the right main bronchus were referred elsewhere due to a lack of appropriate instruments/expertise at the time of their presentation.
In this study, the patient's age was found to be significantly associated with the outcome of treatment among our patients managed for ENT emergencies. Age <5 years was found to be a significant positive predictor of poor outcomes among our patients.
The number of patients recruited for this study was limited because cases with incomplete information were excluded. Furthermore, the sample size is relatively too small to make population-based conclusions.
| Conclusion|| |
Otologic conditions are the most common pediatric emergencies in this study. Most cases are inflammatory diseases, followed by FBs of the ENT, and the majority of the cases can be managed on an outpatient basis. However, FBs of the airway and esophagus require admission and surgical management. Age <5 years was a positive predictor of poor outcome in this study. The provision of appropriate instruments and experts will greatly help in the successful management of pediatric ENT surgical emergencies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mir N, Trilla A, Quinto LL, Molinero M, Asenjo M. Is there a place for otolaryngology in primary care? analysis of different areas. Acta Otorrinolaringol Esp. 2002,53:495-501.
Signorelli LG, Mendes Ede A. Prevalence of otorhinolaryngologic diagnoses in the pediatric emergency room. Int Arch Otorhinolaryngol 2013;17:10-3.
López Amado M, García Sarandeses A, Herranz González-Botas J, López Blanco G, Martínez Vidal J. Appropriateness emergency hospital admissions at an ORL service of a third level hospital. Acta Otorrinolaringol Esp 1993;44:31-4.
Khan AR, Arif S. Ear nose and throat injuries in children. J Ayub Med Coll Abbottabad 2005;17:54-6.
Figueriedo RR, Azevedo AA, Kos AO, Tomita S. Complications of ear, nose and throat foreign bodies. Braz J Otorhinolaryngol 2008;74:7-15.
Jacobstein CR, Baren JM. Emergency department treatment of minors. Emerg Med Clin North Am 1999;17:341-52.
Adoga AA, Okwori ET, Yaro JP, Iduh AA. Pediatric otorhinolaryngology emergencies at the Jos University Teaching Hospital: Study of frequency, management, and outcomes. Ann Afr Med 2017;16:81-4.
] [Full text]
Ibekwe UM. Otorhinolaryngological emergencies in a Tertiary Hospital in Port Harcourt. Niger J Clin Pract 2017;20:606-9.
] [Full text]
Rana AK, Kumar S, Sharma R. Sharma VK. Presentations of pediatric emergencies in a tertiary teaching hospital in North India: An overview. Indian J Otolaryngol Head Neck Surg 2019; https://doi.org/10.1007/s12070-019-01748-1
Yadav M, Yadav D, Naik SB. Spectrum of ENT emergencies at a tertiary care hospital in a rural Area of Haryana, India J Med Sci Clin Res 2017;5:29833-83.
Raj A, Wadhwa V, Jain A. Epidemiological Profile of ENT Emergencies: Our Experience. Indian J Otolaryngol Head Neck Surg 2019;71:301-4.
Hussain G, Iqbal M, Khan SA, Iqbal M, Zaman J. An experience of 42 cases of bronchoscopy at Saidu Group of Teaching Hospitals, Swat. J Ayub Med Coll Abbottabad 2006;18:59-62.
Nisar J, Khaliq BA, Hanan A, Pampori RA. Pediatric ear, nose and throat emergencies Prevalence and management: A hospital-based study. Int J Adv Res 2016;4:1983-7.
Sharma K, Bhattacharjya D, Barman H, Goswami SC. Common Ear, Nose, and Throat problems in pediatric age group presenting to the emergency clinic prevalence and management: A hospital-based study. Indian J Clin Practice 2014;24:756-60.
Tamir SO, Sibbald A, Rupa V, Marchisio P, Homoe P, Daniel SJ, et al
. Guidelines for the treatment of acute otitis media: Why are there worldwide differences? Curr Otorhinol Aryngol Rep 2017;5:101-7.
Nesbit CE, Powers MC. An evidence-based approach to managing acute otitis media. Pediatr Emerg Med Pract 2013;10:1-26.
Al-Mazrou KA, Makki FM, Allam OS, Al-Fayez AI. Surgical emergencies in pediatric otolaryngology. Saudi Med J 2009;30:932-6.
Stoner MJ, Dulaurier M. Pediatric ENT emergencies. Emerg Med Clin North Am 2013;31:795-808.
Shuaibu IY, Usman M A, Chitumu D, Ajiya A, Shofoluwe NA. Nasal foreign bodies among pediatric population in Zaria-Nigeria. J Med Trop 2019;21:100-3. [Full text]
Barman D, Maridal S, Goswami S, Hembram R. Three years audit of the emergency patients in the department of ENT of a rural medical college. J Indian Med Assoc 2012;110:370-4.
Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol 2018;22:146-51.
Saha S, Chandra S, Mondal PK, Das S, Mishra S, Rashid MA, et al
. Emergency Otorhinolaryngolocal cases in Medical College, Kolkata-A statistical analysis. Indian J Otolaryngol Head Neck Surg 2005;57:219-25.
Montague ML, Starritt NE. Epistaxis. In: Watkinson JC, Clarke RW, editors. Scott-Brown's Otorhinolaryngology Head and Neck Surgery. 8th
-ed. New York, NY: CRC press; 2018. p. 241-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]