7.3 Pediatric ENT & Ocular Emergencies

7.3 Pediatric ENT & Ocular Emergencies

Pediatric ear, nose, throat (ENT), and ocular conditions frequently trigger emergency department visits. Because pediatric upper airway anatomy is small and highly distensible, deep neck space infections and airway foreign bodies can cause rapid respiratory compromise. Similarly, ocular trauma and chemical exposures require immediate, systematic interventions to prevent permanent visual impairment.

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Peritonsillar Abscess vs. Retropharyngeal Abscess

Deep neck space infections in children present significant diagnostic and airway management challenges. Differentiating peritonsillar abscess from retropharyngeal abscess relies on age presentation, physical findings, and anatomical localization.

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Pediatric Epistaxis Management & Kiesselbach's Plexus

Over 90% of pediatric nosebleeds originate from Kiesselbach's plexus (also known as Little's area), a highly vascular network located on the anterior cartilaginous nasal septum where branches of the internal and external carotid arteries anastomose.

Common Etiologies

Digital trauma (nose picking), mucosal dryness from dry indoor heat, allergic rhinitis, nasal foreign bodies, and topically administered nasal steroids. Rarely, refractory bleeding suggests underlying coagulopathies (e.g., von Willebrand disease, leukemia) or posterior epistaxis from Woodruff's plexus.

Step-by-Step Emergency Nursing Management

[Patient Position]
Lean forward, chin down
(Prevents blood swallowing & aspiration)
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[Direct Pressure]
Pinch soft tissue of nostrils against septum
Continuously for 10-15 minutes
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[Topical Vasoconstrictor]
Oxymetazoline (Afrin) or Phenylephrine spray
(If bleeding continues after 15 minutes)
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[Refractory Bleeding]
Silver nitrate cautery or anterior nasal packing
(Consult ENT if bleeding persists > 30 mins)

1. Positioning: Sit the child upright and leaning slightly forward with the chin tilted down.

   Avoid: Leaning the head back, which leads to swallowing blood, gastric irritation, vomiting, and potential airway aspiration.

2. Direct Compression: Apply continuous, firm pressure by pinching the soft tissue of the lower nostrils against the nasal septum for 10 to 15 full minutes without releasing pressure to check for bleeding.
3. Topical Vasoconstrictors: If bleeding continues after 15 minutes of continuous compression, clear clots by gentle blowing, then instill topical vasoconstrictor spray (e.g., oxymetazoline 0.05% [Afrin] or phenylephrine) on a cotton ball inserted into the affected nostril, followed by another 10 to 15 minutes of direct pressure.
4. Advanced Interventions: If bleeding persists, assist the clinician with anterior nasal packing (nasal tampons or rapid rhino catheters) or silver nitrate chemical cautery.

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Ocular Emergencies: Chemical Burns, Trauma & Abrasions

Ocular Chemical Burns (Absolute Medical Emergency)

Chemical injuries to the eye mandate immediate resuscitation before any diagnostic evaluation or formal visual acuity testing.

• Alkali Burns (e.g., lye, drain cleaner, ammonia, wet concrete): Most damaging. Cause liquefactive necrosis, saponifying cell membrane lipids and rapidly penetrating into the anterior chamber, causing cataracts, glaucoma, and permanent corneal opacification.
• Acid Burns (e.g., battery acid, bleach): Cause coagulative necrosis, forming a protective protein barrier that limits deeper tissue penetration.

Nursing Action Plan

• Immediate Irrigation: Initiate continuous, high-volume irrigation immediately with sterile normal saline or Lactated Ringer's using an ocular irrigation lens (e.g., Morgan Lens) or IV tubing.
• pH Testing: Continue irrigation until tear film pH reaches a neutral range of 7.0 to 7.4 (measured using pH paper 5 minutes after stopping fluid flow to allow natural tear equilibrium). Irrigation often requires 2 to 4 liters of fluid over 30 to 60 minutes.

Corneal Abrasions

Superficial epithelial defects caused by fingernails, foreign objects, or contact lenses.

• Presentation: Severe eye pain, photophobia, tearing, foreign body sensation, and blepharospasm.
• Diagnosis: Instill fluorescein stain and inspect the cornea under a cobalt blue light or Wood's lamp; abrasions fluoresce bright green.
• Management: Topical broad-spectrum antibiotic drops (e.g., erythromycin or fluoroquinolones for contact lens wearers), oral analgesics.

  Critical Warning: NEVER dispense topical anesthetic drops (e.g., tetracaine, proparacaine) for home use; repeated use causes corneal toxicity, delayed healing, and corneal ulceration/perforation.

Penetrating Ocular Trauma & Open Globe Injury

Full-thickness disruption of the cornea or sclera.

• Clinical Signs: Irregular or teardrop-shaped pupil pointing toward the wound site, hyphema (blood in anterior chamber), subconjunctival hemorrhage, loss of anterior chamber depth, or positive Seidel test (streaming of clear aqueous humor through fluorescein dye under blue light).
• Emergency Nursing Rules:
  • Do NOT place any pressure on the eye. Do not palpate the globe or measure intraocular pressure.
  • Do NOT apply eye drops, ointments, or eye pads.
  • Place a rigid metal or plastic protective shield (Fox shield) resting on the bony margins of the orbit.
  • Keep patient strictly NPO, elevate head of bed 30 degrees, provide IV analgesia, and administer IV antiemetics (e.g., ondansetron) immediately to prevent vomiting and sudden spikes in intraocular pressure that cause extrusion of intraocular contents.

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ENT Foreign Body Removal Safety

Foreign bodies in the ears, nose, and upper respiratory tract are frequent pediatric presentations requiring careful risk assessment.

Button Battery Ingestion / Insertion: Hyperacute Emergency

Button batteries lodged in the nasal cavity, external auditory canal, or esophagus represent an immediate surgical emergency.

• Mechanism of Damage: Electrical current generation rapidly hydrolyzes tissue fluids, producing hydroxide ions (alkaline necrosis) that cause deep liquefactive tissue destruction and tissue perforation within 2 hours.
• Absolute Contraindication: NEVER irrigate a nasal cavity or ear canal containing a button battery. Fluid creates a conductive medium that accelerates chemical leakage, electrical circuit closure, and tissue destruction.

Organic Foreign Bodies (Seeds, Beans, Food Items)

• Mechanism: Organic items are hygroscopic—they absorb moisture from nasal or aural secretions and swell over time, leading to total canal obstruction, pressure necrosis, and difficult extraction.
• Absolute Contraindication: NEVER irrigate organic foreign bodies with aqueous solutions, as moisture causes the item to swell rapidly and become wedged tighter against the canal wall.

Safe Removal Guidelines

• Utilize direct visualization with a high-intensity otoscope or headlamp.
• Select specialized instruments: alligator forceps, right-angle hooks, or suction catheters.
• Ensure proper patient immobilization or procedural sedation to prevent sudden movement and secondary tympanic membrane perforation.