Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 16  |  Issue : 2  |  Page : 81--84

Pediatric otorhinolaryngology emergencies at the Jos University Teaching Hospital: Study of frequency, management, and outcomes


Adeyi A Adoga, Emoche T Okwori, John P Yaro, Andrew A Iduh 
 Department of Otorhinolaryngology, Head and Neck Surgery, Jos University Teaching Hospital, Jos, Plateau State, Nigeria

Correspondence Address:
Adeyi A Adoga
Department of Otorhinolaryngology, Head and Neck Surgery, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State
Nigeria

Abstract

Background: Studies from Nigeria on pediatric otorhinolaryngology (ORL) emergencies are rare in literature with most focusing on emergencies involving individual systems. Objective: The aim of this study is to determine the prevalence of all ORL emergencies among children in our region to provide a baseline data for future health planning. Patients and Methods: This is a 1-year retrospective cross-sectional study of patients aged 16 years and below presenting to the Accident and Emergency Department of the Jos University Teaching Hospital, Jos, Nigeria. Results: A total of 203 otolaryngology emergencies were attended of which 129 (63.5%) were pediatric emergencies. Records of 87 patients were retrievable with age range 2 months to 15 years (mean 3.44 years; standard deviation ± 3.35). There were 55 males and 32 females with a male to female ratio of 1.7:1. The majority of cases were aged under 5 years (64; 73.6%). Acute tonsillitis accounted for 32 (36.7%) cases with 6 (6.9%) having peritonsillar abscesses. Acute pharyngitis accounted for 11 (12.6%) presentations followed closely by foreign bodies (FBs) in the ear with 10 (11.5%) presentations. FB in the throat occurred in 4 (4.6%) patients who had removal under general anesthesia. Three (3.4%) cases of maxillofacial injuries occurred as a result of insurgent terror attacks and 3.4% presented following corrosive substance ingestion. Conservative management was commenced in 76 (87.4%) patients, 23 (26.4%) had surgery with 68 (78.2%) admitted and discharged, 18 (20.7%) treated as outpatients, and 1 (1.1%) died on admission. Otolaryngologists attended most (95.4%) patients. Conclusion: Pediatric ORL emergencies are common in our region involving a wide range of pathologies. Expansion is required in the ORL training of the emergency room physician to enhance emergency services.



How to cite this article:
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;16:81-84


How to cite this URL:
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 [serial online] 2017 [cited 2022 Oct 7 ];16:81-84
Available from: https://www.annalsafrmed.org/text.asp?2017/16/2/81/205276


Full Text



 Introduction



Emergency medicine refers to the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury and involves the initial evaluation, diagnosis, treatment, and disposition of patients requiring urgent medical, surgical, or psychiatric treatment.[1]

This practice can be undertaken in a hospital-based or freestanding emergency department, urgent care clinic, an emergency medical response vehicle, or at a disaster site.

Otorhinolaryngology (ORL) emergencies occur virtually in all communities, and those involving the pediatric age group are considered of great importance as their management differs from those of adults because of life-threatening complications such as airway obstruction. Therefore, they deserve efficient skills and adequate equipment for accurate diagnoses, and early intervention to reduce morbidity and mortality.

These emergencies range from less severe inflammatory presentations of pharyngotonsillitis and acute suppurative otitis media to life-threatening airway obstruction resulting from foreign bodies (FBs) in the airway.

Pediatric ORL emergencies account for one-third of all ORL emergencies.[2],[3]

In a study done in the United States, it was recorded that children accounted for 10%–40% of the total number of patients presenting to the Emergency Department.[4]

Studies from Nigeria only give epidemiological data for pediatric ORL emergencies involving individual systems.[5],[6],[7]

This study aims to determine the prevalence of all ORL emergencies among children in our region, their demographic characteristics, and the type of treatment instituted with the outcomes of treatment to provide a baseline data for future health planning.

 Patients and Methods



Study design

This is a 1-year (January 27, 2013–January 26, 2014) retrospective cross-sectional study of patients aged 16 years and below presenting to the Accident and Emergency Department of the Jos University Teaching Hospital. Approval for this study was obtained from the Ethical Clearance Committee of the teaching hospital.

Procedure

Records for the patients seen during the study were obtained and analyzed for age, gender, and time of presentation, the pathology at presentation, the treatment modality offered, and the outcome of treatment.

Statistical analysis

Data obtained was entered into the Statistical Products and Services Solutions (SPSS) software version 16 (SPSS Inc., Chicago, IL, USA) and analyzed.

The results are presented in simple descriptive tables.

 Results



A total of 203 otolaryngology emergencies were attended during the study of which 129 (63.5%) were pediatric emergencies. The records of 87 patients were retrievable, and these were analyzed. The patients were aged between 2 months and 15 years with a mean age of 3.44 years (standard deviation [SD] ±3.35). There were 55 males and 32 females giving a male to female ratio of 1.7:1. The majority of patients were under 5 years of age (64; 73.6%) [Table 1].{Table 1}

The time of presentation of patients ranged from <1 to 12 days (mean = 3.44 days; SD ± 2.53).

Acute tonsillitis accounted for 32 (36.7%) presentations and 6 (6.9%) of these presented with peritonsillar abscess, and they all had incision and drainage of their abscesses but only two represented to have interval tonsillectomy which is our departmental management policy for a peritonsillar abscess. Acute pharyngitis accounted for 11 (12.6%) presentations followed closely by FB in the ear with 10 (11.5%) presentations [Table 2] of which beads were the most common, and others being paper, earrings, and bean seeds in ascending order of frequency which were all removed under direct vision with Jobson Horne probe and Tilley's forceps. FB in the throat occurred in 4 (4.6%) patients who had removal under general anesthesia with 1 (1.1%) patient requiring an emergency tracheostomy; the others were removed from the pharynx at attempted oroendotracheal intubation. All patients with acute infective conditions were managed conservatively at initial presentation.{Table 2}

The 3 (3.4%) cases of maxillofacial injuries presenting in this study were as a result of insurgent terror attacks on rural communities. These were carefully repaired and the patients discharged without events.

Three (3.4%) patients presented following corrosive substance ingestion (alkali in all cases). They had nasogastric tube insertion at presentation, admitted, and managed conservatively. Management of these patients was multidisciplinary involving the cardiothoracic surgery team.

Patients presenting with epistaxis were managed by nasal packing with gauze packs and insertion of merocel.

Medical management was commenced for 76 (87.4%) patients attended and eventually, a total of 23 (26.4%) had surgical intervention due to failure of medical treatment in 12 (13.8%) patients. Sixty-eight (78.2%) were admitted and discharged, 18 (20.7%) treated as outpatients, whereas 1 (1.1%) patient died on admission [Table 3].{Table 3}

The attending doctors at presentation were 83 (95.4%) patients by otolaryngologists and 4 (4.6%) by medical officers in the Accident and Emergency Department who referred to the otolaryngology department following stabilization of patients.

 Discussion



Literature on pediatric ORL emergencies is scarce, especially in Nigeria with most studies on the epidemiology of individual pediatric ORL emergencies.

This study shows a significant prevalence (63.5%) of attended pediatric ORL emergencies with the majority of patients aged between 2 months and 5 years. A hospital-based study among all age groups from Korle-Bu, Ghana recorded a peak age incidence of 0–9 years.[8]

Acute infections of the ear, nose, and throat is one of the most common causes of pediatric emergency presentations,[9] and this study shows acute tonsillitis to be the most common with 6.9% presenting as peritonsillar abscesses. This is similar to the study by Fernández Cano and Martín Carballo.[10] About 75% of tonsillitis occurring in children is caused by viruses, but most of these cases are treated with antibiotics because though many clinical criteria exist for differentiating bacterial from viral tonsillitis, their sensitivity for identifying one from the other is low.[11],[12],[13] All patients (n = 6) presenting with a peritonsillar abscess in this study had incision and drainage of their abscesses, but only two presented to have interval tonsillectomy which is the management protocol of our department. The rest of the patients were lost to follow-up a common phenomenon among patients in our environment.

All our patients with acute tonsillitis were admitted and commenced on parenteral antibiotics. The main aim is to decrease the possibility of suppurative and nonsuppurative complications associated with Group A beta-hemolytic Streptococcus infection and to minimize its transmission in the community.[13]

Acute suppurative otitis media is the second most prevalent otologic manifestation recorded in this study [Table 2]. Acute otitis media is common in children, and it is due to the wider and more horizontally-oriented eustachian tube in this age group resulting in translocation of infection from the pharynx to the tympanic cavity. It accounts for one-third of the pathology seen in the first 5-year life.[14] These children will present with fever and otalgia; therefore, otoscopy is highly recommended to commence early treatment and prevent the lifelong sequel of impairment of hearing and speech acquisition.

Most studies record FB as the most common pediatric emergency presentation [9],[15],[16] which contrasts with our finding, in which FB accounted for the second largest group of emergencies. Children are continually exploring their surroundings and tend to place objects in the ear, nose, and throat passages constituting major morbidity and mortality. FB in the throat/airway are a major threat to life and should be managed by the otolaryngologist usually under general anesthesia as it is shown in our study. Those occurring in the ear and nose are usually not considered as emergencies, but their management should be executed by the skilled physician, especially FB in the ear in, which attempts at removal by the unskilled can result in damage to the tympanic membrane and middle ear structures including the facial nerve.[17]

Injuries occurring in children are not uncommon. They are an avoidable cause of disability.[18] With the increase in the incidence of insurgent terror attacks on communities in our region, injuries of various kinds have been recorded,[19] and unfortunately, children are not spared in these events as is seen in the present study. The majority of those affected do not make it to the hospital alive. Reducing the incidence of insurgent attacks and communal clashes is the responsibility of government and can be achieved by the improvement of human development via reduction of poverty, improvement of the economy and job creation.

Airway management in children is an important part of ORL emergency care in which early and accurate diagnosis is lifesaving. The most common diseases requiring such intervention are acute viral laryngotracheobronchitis, epiglottitis, and bacterial tracheitis.[20] Others will include diphtheria, laryngomalacia, and the presence of FB. Our patients with infective airway diseases were managed conservatively without major airway intervention probably because of early presentation enough for conservative management to suffice. The management of FB in the airway depends on the site of impaction with those in the pharynx being easier to remove than those in the lower respiratory tree.

Caustic substance ingestion remains a major health concern as seen in this study. In as much as it is stated above that children are continually exploring their environment, certain caustic agents are stored in inappropriate containers from which children can ingest. To reduce this occurrence, preventive parental health education is required and proper legislation to ensure corrosive agents are stored in childproof containers.[21] The importance of multidisciplinary management of these patients is highlighted in our study.

The otolaryngologist is called most times to the Accident and Emergency Department to manage these presentations as many accidents and emergency physicians are not adequately trained to handle such cases. This explains why the otolaryngologist attended the bulk of our patients. Training personnel in this regard will increase skill in the management of minor cases and reduce the burden on ORL emergency services.

 Conclusion



Pediatric ORL emergencies are common in our region and involve a wide spectrum of pathologies with acute tonsillitis forming the bulk of our cases. The majority of the patients can be managed conservatively, but a significant number requires surgical intervention. Expansion is required in the ORL training of the emergency room physician to enhance emergency services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Definition of emergency medicine. Model of the clinical practice of emergency medicine [policy statement]; Approved August 2007. Ann Emerg Med 2008;52:189-90. Available from: secure.jbs.elsevierhealth.com [Last accessed 2017 Feb 12].
2Pracy R. Introduction. In: Evans JN, editor. Scott-Brown's Otolaryngology. 5th ed., Vol. 6. London: Butterworth; 1987. p. 1-3.
3Tunkel DE, Cull WL, Jewett EA, Brotherton SE, Britton CV, Mulvey HJ. Practice of pediatric otolaryngology: Results of the future of pediatric education II project. Arch Otolaryngol Head Neck Surg 2002;128:759-64.
4Jacobstein CR, Baren JM. Emergency department treatment of minors. Emerg Med Clin North Am 1999;17:341-52, x.
5Osunde OD, Amole IO, Ver-or N, Akhiwu BI, Adebola RA, Iyogun CA, et al. Pediatric maxillofacial injuries at a Nigerian teaching hospital: A three-year review. Niger J Clin Pract 2013;16:149-54.
6Afolabi OA, Kodiya AM, Bakari A, Ahmad BM. Otological emergencies among the Northern Nigerian children. East Cent Afr J Surg 2008;13:91-5.
7Ibekwe MU, Onotai LO, Otaigbe B. Foreign body in the ear, nose and throat in children: A five year review in Niger delta. Afr J Paediatr Surg 2012;9:3-7.
8Kitcher E, Jangu A, Baidoo K. Emergency ear, nose and throat admissions at the Korle-Bu Teaching Hospital. Ghana Med J 2007;41:9-11.
9Sharma 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 Pract 2014;24:756-60.
10Fernández Cano G, Martín Carballo G. Pediatric emergencies attended at a primary care clinic (II): Epidemiological study. Aten Primaria 2000;26:81-5.
11American Academy of Pediatrics. Group A streptococcal infections. In: Pichering LK, editor. Red Book: 2003 Report of the Committee of Infectious Diseases. 26th ed. ELK Grove Village, IL: American Academy of Pediatrics; 2003. p. 573-84.
12Sih T, Clement PA. Pediatric Nasal and Sinus Disorders. Boca Raton, FL: Taylor Publishing; 2005.
13Sih TM, Bricks LF. Optimizing the management of the main acute infections in pediatric ORL: Tonsillitis, sinusitis, otitis media. Braz J Otorhinolaryngol 2008;74:755-62.
14Pestalozza G, Romagnoli M, Tessitore E. Incidence and risk factors of acute otitis media and otitis media with effusion in children of different age groups. Adv Otorhinolaryngol 1988;40:47-56.
15Al-Mazrou KA, Makki FM, Allam OS, Al-Fayez AI. Surgical emergencies in pediatric otolaryngology. Saudi Med J 2009;30:932-6.
16Stoner MJ, Dulaurier M. Pediatric ENT emergencies. Emerg Med Clin North Am 2013;31:795-808.
17Saha 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.
18Singh I, Gathwala G, Yadav SP. Ear, nose and throat injuries in children. Pak J Otolaryngol 1993;9:133-5.
19Adoga AA, Ozoilo KN. The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center. J Emerg Trauma Shock 2014;7:77-82.
20Devlin B, Golchin K, Adair R. Paediatric airway emergencies in Northern Ireland, 1990-2003. J Laryngol Otol 2007;121:659-63.
21Uygun I. Caustic oesophagitis in children: Prevalence, the corrosive agents involved, and management from primary care through to surgery. Curr Opin Otolaryngol Head Neck Surg 2015;23:423-32.