1. E.N.T. Emergencies in children


Dr. Naim Manhas.
E.N.T. Specialist
King Abdul Aziz Hospital

Dr. Naim Manhas
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2. Dr. Naim Manhas
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3. Neonatal emergencies
Choanal atresia
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.

Dr. Naim Manhas
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4. Neonatal emergencies
Bilateral Choanal atresia
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 )

Dr. Naim Manhas
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5. Dr. Naim Manhas
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6. 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.

Dr. Naim Manhas
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7. Bilateral Choanal Atresia

The McGovern Nipple- with enlarged
hole through which neonate can breath
as well as feed.

Intubation / tracheotomy.
Dr. Naim Manhas
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8. 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.

Dr. Naim Manhas
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9. 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.
Dr. Naim Manhas
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10. Dr. Naim Manhas
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11. Infants
Subglottc hemangioma / Airway
Infantile Hemangioma.
 Typically unilateral, can be
circumferential.
 Hemangiomas progress from an intial
Proliferative phase to Involutional phase.

Dr. Naim Manhas
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12. 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.

Dr. Naim Manhas
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13. 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.

Dr. Naim Manhas
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14. Investigations


Sagittal computed
tomography image
with contrast :Showing contrast
enhancing Airway
Infantile
Hemangioma in
posterior glottis
Dr. Naim Manhas
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15. Investigations


Confirmation of the
diagnosis is by
Endoscopic
Examination.
Typical finding :Unilateral Sessile,
submucosal
compressible
vascular lesion in
the subglottis.
Dr. Naim Manhas
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16. Treatment
Goals of treatment : Overcome the Airway obstruction
 Avoidance of long standing
complications like subglottic stenosis.

Dr. Naim Manhas
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17. Treatment
Medical therapy / Surgical therapy
 There are no standardized evaluation
protocols for Airway Infantile
Hemangiomas , leading to broad
variations in management.

Dr. Naim Manhas
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18. 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
Dr. Naim Manhas
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19. Intra-Lesional injections

Multiple injections

Local oedma

Airway compromise

Prolonged intubation
Dr. Naim Manhas
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20. Intra-Lesional injections
Interferon : Antiangiogenic activity in proliferative
phase
 Rebound effect
 Prolonged period can lead to
development of spastic diplegia

Dr. Naim Manhas
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21. surgical therapy
Laser therapy : Carbon diaoxide and KTP ( potassium
titanyl phosphate) lasers are beneficial
with only 25% incidence of subglottic
stenosis.

Dr. Naim Manhas
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22. 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.

Dr. Naim Manhas
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23. 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.

Dr. Naim Manhas
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24. Dr. Naim Manhas
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25. 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.
Dr. Naim Manhas
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26. 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.
Dr. Naim Manhas
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27. 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.
Dr. Naim Manhas
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28. 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.

Dr. Naim Manhas
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29. 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.
Dr. Naim Manhas
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30. 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.
Dr. Naim Manhas
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31. Partially occluding bronchial foreign body
acts as a Ball-Valve causing hyperexpansion 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.

Dr. Naim Manhas
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32. 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
Dr. Naim Manhas
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33. 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.
Dr. Naim Manhas
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34. 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.
Dr. Naim Manhas
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35. 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
Dr. Naim Manhas
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36. 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
Dr. Naim Manhas
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37. 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.
Dr. Naim Manhas
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38. 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 .

Dr. Naim Manhas
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39. 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.

Dr. Naim Manhas
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40. Dr. Naim Manhas
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