Pediatric ENT Exam

Child's Medical History

Begin by asking the caregiver about symptoms and key background information:

• Ear pain or discomfort
• Hearing loss or delayed response to sounds
• Balance issues or dizziness
• Speech or language delays
• Breathing difficulty, snoring, or nasal congestion
• Swallowing difficulties
• Past ENT problems or recurrent infections
• Recent trauma to the ear, nose or throat

Physical Examination

Ears

Use an otoscope to assess the ear canal and tympanic membrane. Look for:

• Redness, swelling or discharge
• Tympanic membrane perforation
• Foreign bodies
• Signs of infection or inflammation
• Hearing abnormalities (whisper test / tuning fork)

Nose

Inspect the nasal passages for:

• Obstruction or congestion
• Discharge or epistaxis
• Deviated septum or structural abnormalities
• Foreign bodies

Throat

Use a tongue depressor and light to examine:

• Redness, swelling or exudates
• Tonsillitis or pharyngitis
• Ulcers or oral lesions
• Foreign bodies
• Dysphagia
• Cervical lymphadenopathy

Diagnostic Evaluation

Further tests may include:

• Pediatric audiometry
• CT or MRI imaging
• Flexible nasopharyngoscopy
• Throat or nasal swab cultures

Pediatric ENT Red Flags

These features should prompt urgent senior review, possible ENT referral, and consideration for admission:

Quick Pediatric ENT Algorithm for A&E

Use this as a quick mental flow in the Emergency Department:

1. Initial Impression: Sick or Not Sick?
   • Check ABCDE immediately.
   • If any airway or breathing compromise → call for senior help, anaesthetics/ENT, prepare for airway support.
2. Airway/Breathing Symptoms Present?
   • Stridor / respiratory distress: High flow oxygen, nebulised adrenaline if indicated, steroids, keep child calm, early ENT/anaesthetics.
   • Drooling / inability to swallow / tripod position: Do not attempt aggressive oral examination, keep child upright, urgent ENT and anaesthetics.
3. If Airway Stable – Identify Main Complaint
   • Ear pain / discharge: Consider otitis media/externa, foreign body, TM perforation.
   • Sore throat: Tonsillitis, pharyngitis, quinsy, viral URTI.
   • Nasal symptoms: Rhinitis, sinusitis, epistaxis, nasal foreign body.
   • Hearing or speech delay: Glue ear, conductive hearing loss, sensorineural loss.
4. Look for Red Flags
   • If any present → escalate, consider imaging, IV antibiotics, admission.
   • If no red flags and child well → manage as outpatient with safety netting.
5. Decide on Disposition
   • Admit: Airway/breathing issues, systemic toxicity, severe pain not controlled, concern for mastoiditis, quinsy, deep neck space infection.
   • Discharge: Stable child, no red flags, clear diagnosis, caregiver understands red flags and follow-up advice.

Common Pediatric ENT Emergencies

Key emergencies you will often see in A&E and their initial management priorities:

1. Stridor & Acute Upper Airway Obstruction

• Keep child with caregiver, avoid upsetting them.
• High flow oxygen, consider nebulised adrenaline if indicated.
• Give systemic steroids if appropriate (e.g. dexamethasone).
• Urgent ENT/anaesthetic review for potential airway intervention.
• Do not force the child to lie flat or cry unnecessarily.

2. Inhaled or Impacted Foreign Body (Airway)

• Sudden onset cough, wheeze, or unilateral decreased air entry.
• If complete obstruction and child conscious → age-appropriate choking algorithm (back blows, chest/abdominal thrusts).
• If partial obstruction and stable → avoid blind sweeps, urgent ENT/anaesthetics for bronchoscopy.
• Consider imaging but do not delay airway management.

3. Nasal Foreign Body

• Common in toddlers; unilateral foul-smelling or bloody discharge.
• If visible and cooperative child → consider simple removal in ED (parent’s kiss technique, suction, hook) if trained and safe.
• Avoid pushing object further back.
• ENT referral if not easily removed, if button battery, or if penetrating object.

4. Epistaxis

• Sit child up, head slightly forward, pinch soft part of nose continuously for 10–15 minutes.
• Reassure child and caregiver, avoid swallowing blood.
• Consider topical vasoconstrictor and local pressure if persistent.
• ENT referral for recurrent, severe, or posterior bleeds.

5. Tonsillitis & Peritonsillar Abscess (Quinsy)

• Severe sore throat, trismus, muffled “hot potato” voice, unilateral swelling, uvula deviation.
• ABC assessment – ensure no airway compromise.
• IV fluids, analgesia, antibiotics if indicated.
• ENT referral for drainage of quinsy and admission if unwell.

6. Mastoiditis

• Post-auricular swelling, erythema, tenderness, protruding pinna, often following otitis media.
• Systemically unwell child, fever, irritability.
• Urgent ENT referral, IV antibiotics, and imaging if required.

7. Deep Neck Space Infection

• Neck swelling, torticollis, severe pain, fever, drooling, trismus.
• Airway evaluation is the first priority.
• IV antibiotics, imaging (CT neck with contrast if safe), urgent ENT and anaesthetics.

Always document red flags, safety net advice, and review arrangements clearly in the notes.