ENT Guide for Pediatricians

Practical tools for daily consultation and referral criteria

Introduction

Welcome, fellow pediatrician! This interactive guide has been designed to be your quick and practical resource in daily consultation, addressing the most common otorhinolaryngological pathologies in the pediatric population. Our goal is to strengthen your confidence in initial management and provide you with clear criteria for knowing when it is time to refer to an ENT specialist.

Pediatric otolaryngology is a vast field, but by knowing the key points and red flags, you will be able to offer excellent care to your little patients.

Advice: Use the navigation menu to quickly jump to the section you are interested in. Click on the titles of each pathology to expand the information.

General Prevention Tips: Encouraging exclusive breastfeeding in the first 6 months, avoiding exposure to tobacco smoke, promoting up-to-date vaccination (especially against pneumococcus and influenza), and educating about regular nasal hygiene with saline are key measures to reduce the incidence of ENT infections in children.

Otitis

Acute Otitis Media (AOM)

Diagnosis:

  • Otomicroscopy: Bulging of the tympanic membrane, marked erythema, opacification, decrease or abolition of mobility (pneumo-otoscopy). Fluid is often seen in the middle ear.
  • Symptoms: Otalgia (ear pain), irritability, fever, otorrachia (suppuration, if there is perforation).

Management:

  • Pain Management: Analgesia is essential. Start with paracetamol (10-15 mg/kg/dose every 4-6h) or ibuprofen (5-10 mg/kg/dose every 6-8 hours). Ensure that parents understand the importance of regularly administering pain relievers for the child's comfort.
  • Antibiotics:
    • Starting criteria: Children < 6 months, children 6 months-2 years with a certain or severe diagnosis, children > 2 years with a certain and severe diagnosis or with symptoms that do not improve in 48-72 hours.
    • Antibiotic of choice: Amoxicillin (80-90 mg/kg/day in 2-3 doses). If there has been no improvement after 48-72 hours of amoxicillin, amoxicillin-clavulanate can be considered.
    • Duration: 5-7 days for uncomplicated cases; 10 days for children < 2 years or severe AOM.
  • Expectant management: In children > 2 years with non-severe AOM and uncertain diagnosis. Close monitoring is crucial.
Mini-Clinical Case: AOM or not AOM?

10-month-old patient, with a cold for 3 days, irritable and **high fever (39°C)**. Parents report that he touches his ear. On otoscopy, tympanic membrane was erythematous, but without clear bulging, and somewhat opaque. Preserved mobility to the pneumo-otoscope.

Otitis Media with Effusion (OME) / Serous Otitis

Diagnosis:

  • Fluid accumulation in the middle ear without signs or symptoms of acute infection.
  • Otomicroscopy: Retracted, opaque tympanic membrane, with air-fluid level or bubbles. Mobility greatly diminished or abolished.
  • Symptoms: Conductive hearing loss (mainly), sensation of blocked ear, language delay (in young children), mild or intermittent otalgia. Often asymptomatic.

Management:

  • Observation: Most cases resolve spontaneously within 3 months. Periodic monitoring of hearing and language.
  • Treatment of the underlying cause: Consider allergies, gastroesophageal reflux (if symptoms present).
  • Not recommended: Antibiotics, antihistamines, decongestants, systemic oral corticosteroids for OME.
When to Refer to ENT for OME?
  • Persistent OME for more than 3 months.
  • Documented significant hearing loss (>20-25 dB) or affecting language/learning development.
  • Signs of structural involvement of the eardrum (retraction pockets, atelectasis, cholesteatoma).
  • Associated symptoms: imbalance, vertigo.
  • Children with associated syndromes (e.g. Down, cleft palate) or facial clefts.
Otitis Externa (OE)

Diagnosis:

  • Inflammation of the external auditory canal.
  • Symptoms: Severe otalgia (especially when swallowing, chewing or moving the pinna), pruritus, otorrachia, auricular fullness, hearing loss.
  • Otomicroscopy: Erythema and edema of the external auditory canal. There may be discharge, debris, or pain to the touch. Tympanic membrane generally normal.
  • Risk factors: Exposure to water ("swimmer's ear"), local trauma (sticks, foreign objects), eczema, use of hearing aids.

Management:

  • Cleaning: If there is a lot of secretion or debris, gently clean the canal with irrigation (if there is no perforation) or aspiration.
  • Topical antibiotics: Otic drop with antibiotic (e.g. Ciprofloxacin, polymyxin B/neomycin/hydrocortisone) +/- corticosteroid. Ensure that the drops reach the duct (position the child, pull the pavilion).
  • Painkillers: For pain, paracetamol or ibuprofen.
  • Avoid humidity: Do not wet the ear during the treatment (use cotton plugs with Vaseline when bathing).
When to Refer to ENT for OE?
  • Failure of topical treatment in 48-72 hours.
  • Extension of the infection outside the duct (periauricular cellulitis, lymphadenitis).
  • Malignant external otitis (rare in children, but serious in immunosuppressed, diabetics or those with chronic diseases).
  • Diagnostic doubts, difficult otoscopy.
  • Impacted foreign bodies.

Rhinosinusitis

Acute Viral Rhinosinusitis (Common Cold)

Diagnosis:

  • Nasal congestion, rhinorrhea (clear or mucopurulent), cough, sneezing, odynophagia.
  • Duration of less than 10 days, without progressive worsening.
  • It is the most frequent diagnosis of upper respiratory infections.

Management:

  • Symptomatic: Nasal washes with physiological saline (abundant and frequent), ambient humidification.
  • Hydration: Ensure good fluid intake.
  • Antipyretics/analgesics: If there is fever or discomfort.
When to suspect Acute Bacterial Rhinosinusitis (ARBS)?
  • Persistence: Respiratory symptoms that persist without improvement for more than 10-14 days.
  • Deterioration: Worsening of symptoms (high fever, purulent rhinorrhea, cough) after initial improvement ("double worsening" pattern).
  • Severe Onset: **High fever (39°C)** and purulent rhinorrhea (purulent sinusitis) for at least 3 consecutive days.
Acute Bacterial Rhinosinusitis (RSBA)

Diagnosis: Based on the suspicion criteria mentioned above.

Management:

  • Antibiotics:
    • First line: Amoxicillin (80-90 mg/kg/day).
    • Second line (or if initial failure/resistance risk): Amoxicillin-clavulanate.
    • Alternatives (penicillin allergy): Cefdinir, Cefpodoxime, Clindamycin (with caution due to resistance).
    • Duration: 10 days is the most common, but may vary depending on the response (up to 7 days without fever and clinical improvement).
  • Support measures: Continue with nasal washes.
When to Refer to ENT for Rhinosinusitis?
  • Suspected complications (orbital: periorbital edema, proptosis, limitation of eye movements, diplopia; intracranial: severe headache, neurological changes, seizures, meningitis, abscess). Medical Emergency!
  • Failure of adequate antibiotic treatment (persistence of fever and symptoms for more than 3 days with antibiotics).
  • Recurrent RSBA (**3 episodes in 6 months or 4** episodes in 12 months).
  • Suspected chronic rhinosinusitis (symptoms for > 12 weeks).
  • Predisposing factors (cystic fibrosis, primary ciliary dyskinesia, immunodeficiencies, ciliary dyskinesia) with severe/recurrent RSBA.

Pharyngotonsillitis

Acute Viral Pharyngotonsillitis

Diagnosis:

  • Generally accompanied by cold symptoms (rhinorrhea, cough, conjunctivitis, dysphonia).
  • There may be rash, diarrhea, oral ulcers (e.g. herpangina).
  • Tonsils erythematous, sometimes with nonpurulent exudate or vesicles.

Management:

  • Symptomatic: Analgesics/antipyretics (paracetamol, ibuprofen). Pain management is key to ensure hydration and comfort.
  • Gargle with warm salt water (in older, cooperative children).
  • Cold or hot liquids (according to the child's preference), ice cream, soft foods.
  • Adequate hydration.
Streptococcal pharyngotonsillitis (GAS)

Diagnosis:

  • Sudden onset of odynophagia, high fever, headache, abdominal pain, nausea/vomiting.
  • Tonsillar purulent exudate, petechiae in the soft palate ("strawberry tongue"), painful and prominent anterior cervical lymphadenopathy.
  • Absence of cough and significant rhinorrhea are indicators of suspicion.
  • Streptococcal antigen rapid diagnostic test (RADT) or throat culture for confirmation.

Management:

  • Antibiotics: To prevent rheumatic fever and shorten the duration of the disease.
  • Choice: Oral Penicillin V (or Amoxicillin, preferable for taste and dosage, 50 mg/kg/day in 2-3 doses, max 1000 mg/dose).
  • Alternatives: Cephalosporins (Cefalexin, Cefadroxil), macrolides (Azithromycin 5 days) in those allergic to penicillin.
  • Duration: 10 days (except azithromycin 5 days).
When to Refer to ENT for Pharyngotonsillitis?
  • Recurrent tonsillitis: Paradise criteria (classically 7 episodes in 1 year, 5/year in 2 years, or 3/year in 3 years, medically documented).
  • Significant obstructive sleep apnea (OSA) associated with tonsillar hypertrophy.
  • History of peritonsillar abscess or pharyngeal cellulitis.
  • Suspected peritonsillar abscess (lockjaw (difficulty opening the mouth), uvula deviation, "hot potato" voice, very severe odynophagia, unilateral bulging of the tonsillar pillar). Emergency!
  • Poor response to appropriate antibiotic treatment.
  • Severe dysphagia that prevents oral hydration and nutrition.
  • Suspicion of other causes (e.g. tumor).

Adenoids and Tonsils

Adenoid Hypertrophy

Symptoms:

  • Chronic nasal obstruction, persistent oral breathing.
  • Loud snoring, sleep apnea (observed breathing pauses, awakenings).
  • Chronic rhinorrhea, nasal voice (closed rhinolalia, "duck voice").
  • Otitis media with recurrent or persistent effusion.
  • Dental malocclusion, "adenoid facies" (long face, dark circles, open mouth).
  • It may be associated with nocturnal enuresis or poor school performance.

Diagnosis:

  • Clinical, based on anamnesis and physical examination.
  • Flexible nasal endoscopy (in the ENT consultation, it is the most precise method).
  • Lateral x-ray of the cavum (can be useful, but has lower sensitivity and specificity).

Management:

  • Initially: Frequent saline nasal washes and topical nasal corticosteroids (e.g. Fluticasone, Mometasone) for 4-6 weeks. Re-evaluate.
  • Management of allergies if present.
When to Refer to ENT for Adenoid Hypertrophy?
  • Severe symptoms of nasal obstruction or OSA that affect quality of life, sleep, behavior or development (e.g. growth retardation, attention deficit).
  • Otitis media with persistent effusion associated with significant hearing loss.
  • Progressive facial or dental deformities.
  • Suspected other causes of nasal obstruction (e.g. nasal polyps, choanal stenosis, tumors).
  • Frequent nosebleeds due to chronic congestion.
Tonsillar hypertrophy

Symptoms:

  • Dysphagia (difficulty swallowing solid foods, choking).
  • Snoring and obstructive sleep apnea (if they are very large and obtrusive).
  • Dull or "pasty" voice.
  • Recurrent tonsillitis (see Pharyngotonsillitis section).

Management:

  • Observation if there are no significant symptoms.
  • Consider surgery (tonsillectomy) **if there is significant obstructive sleep apnea syndrome or recurrent tonsillitis (see criteria).**
Tonsillectomy Criteria:
  • Documented moderate to severe obstructive sleep apnea (confirmed by polysomnography).
  • Recurrent tonsillitis with Paradise criteria.
  • Recurrent peritonsillar abscess.
  • Suspicion of malignancy (unilaterality, rapid growth, marked asymmetry).
  • Significant difficulty swallowing, speaking, or breathing due to tonsillar size.
  • Cardiac problems secondary to chronic OSAS (cor pulmonale).

Dysphonia

Common Causes of Dysphonia in Children

Acute Viral Laryngitis:

  • Most common cause of acute dysphonia. Associated with Acute Respiratory Infection (ARI). Barking cough, inspiratory stridor (croup).
  • Management: Ambient humidification, oral dexamethasone (0.15-0.6 mg/kg single dose), observation.

Vocal Nodules ("Nodulo Cries"):

  • Chronic dysphonia (hoarseness) due to vocal misuse or abuse (excessive shouting, chronic throat clearing, use of the voice in noisy environments).
  • Rough, hoarse voice, with difficulty maintaining voice.
  • Management: voice therapy with a speech therapist is the pillar of treatment.

Laryngomalacia:

  • Most common congenital anomaly of the larynx. Inspiratory stridor of neonatal onset that worsens with crying, feeding, or supine position. Generally improves with age.
  • Mild to moderate dysphonia may be present.
  • Management: Observation for most cases. It rarely requires surgery (supraglottoplasty) in severe cases (growth impairment, severe respiratory distress).
When to Refer to ENT for Dysphonia?
  • Persistent dysphonia for more than 2-3 weeks without clear cause (post-viral, etc.).
  • Dysphonia associated with respiratory difficulty (stridor, retractions, cyanosis). Emergency!
  • Sudden or progressive voice change without apparent cause.
  • Suspected laryngeal structural pathology (laryngeal papillomatosis, cysts, laryngeal clefts, vocal cord paralysis, subglottic hemangiomas).
  • Failure of voice therapy for vocal nodules.
  • History of prolonged intubation.

Foreign bodies

Nasal Foreign Body

Diagnosis:

  • Unilateral purulent, foul-smelling rhinorrhea (unilaterality is key).
  • Unilateral epistaxis.
  • Unilateral nasal obstruction.
  • Direct visualization (nasal specula and good lighting are often required).
  • The child may deny the introduction of the object.

Management:

  • Try to remove with bayonet forceps (with direct vision), earwax hook (curved), or Frazier aspirator. The technique must be gentle to avoid pushing the object further in or damaging the mucosa.
  • "Mother's kiss" maneuver: Blow air into the child's mouth (mouth-to-mouth) while occluding the unaffected nostril. It can be effective for small, unimpacted objects.
  • Using topical vasoconstrictors (eg, oxymetazoline) before attempted extraction may help reduce edema.
Caution! The button batteries They are a chemical emergency: they can cause severe liquefaction necrosis within a few hours. URGENT referral and immediate extraction! Other dangerous objects are magnets (if there is more than one, risk of puncture due to compression).
When to Refer to ENT for Nasal CE?
  • Inability to extract safely in the primary care consultation.
  • Suspected septal perforation or significant damage to the mucosa.
  • Foreign body type button battery or magnet.
  • Associated severe pain, facial edema or fever (suspected infection).
  • Foreign body lodged in a posterior position or in an uncooperative child.
Auditory Foreign Body

Diagnosis:

  • Otalgia, feeling of fullness, hearing loss, irritability.
  • Direct visualization through otoscopy.
  • The child may be asymptomatic and the EC is discovered incidentally.

Management:

  • Inanimate objects: Attempt extraction with alligator clip, wax curette, or lavage (irrigation) if the object is not hygroscopic (e.g. seeds) and the tympanic membrane is intact and well visualized. DO NOT wash if perforation is suspected.
  • Insects: Instill a few drops of mineral oil, lidocaine or alcohol to immobilize/kill the insect before attempting extraction. This reduces discomfort and the risk of trauma.
Caution! Do not attempt extraction if there is no complete visualization of the object, adequate instruments, or if the child does not cooperate. The risk of pushing the object further in or damaging the eardrum or canal is high.
When to Refer to ENT for Auditory CE?
  • Inability to extract safely.
  • Severe pain, bleeding, or suspected tympanic perforation.
  • Foreign body impacted or stuck to the wall of the canal.
  • Foreign body that is a button battery (risk of burns).
  • Very uncooperative child requiring sedation.
Pharyngo-Laryngeal-Oesophageal Foreign Body

Diagnosis:

  • Symptoms in the digestive tract (pharynx/esophagus): Dysphagia (difficulty swallowing solids/liquids), odynophagia, sialorrhea (drooling), chest/abdominal pain, feeling of "something stuck."
  • Symptoms in the airway (larynx/trachea/bronchi): Sudden cough, choking, choking, stridor (high-pitched sound when breathing), dyspnea (shortness of breath), cyanosis, voice change.
  • Chest and neck x-ray (AP and lateral) if the object is radiopaque.
  • The medical history is crucial: what object, how it occurred, symptoms.

Management (Emergency!):

  • Airway commitment: If there is respiratory compromise (severe stridor, dyspnea, cyanosis, inability to speak/cry), Initiate unobstruction maneuvers according to age (Heimlich maneuver in children over 1 year of age; interscapular claps and chest compressions in infants) and urgent transfer to the hospital emergency room!
  • If the child is asymptomatic (or has mild symptoms) and the object is small and blunt (e.g. coin), progression can be observed. However, surveillance is strict.
  • Button batteries and magnets in the esophagus are an emergency and require immediate removal.
URGENT referral to ENT/Digestive/Emergency Services!
  • Any suspicion of a foreign body in the airway.
  • Esophageal foreign bodies, especially button batteries, magnets, or sharp objects.
  • Intense pain, severe dysphagia that prevents hydration or oral intake.
  • Impacted foreign bodies.

Hearing loss

Types and Detection

Main types:

  • Driving: Problem in the outer or middle ear that prevents sound transmission (e.g. OME, earwax plug, atresia, otosclerosis, tympanic perforation). They are usually reversible.
  • Neurosensory: Problem in the inner ear (cochlea) or auditory nerve (e.g. congenital, ototoxic, meningitis, genetics). They are usually permanent.
  • Mixed: Combination of both types.

Detection and Alarm Signs:

  • Neonatal Hearing Screening: Mandatory in most countries (otoacoustic emissions, automated brainstem auditory evoked potentials). A failure requires referral for diagnostic testing.
  • Red flags in consultation (depending on age):
    • Infants (0-6 months): Do not be startled by loud noises, do not react to the parents' voice, do not babble at 6 months.
    • 6-12 months: Not turning the head towards the sound source, not responding when called by name, absence of disyllables ("mom", "dad").
    • 12-24 months: Do not follow simple orders, do not use single words with meaning.
    • Preschoolers/Schoolchildren: Delay in language development, articulation problems, need for high volume on TV/radio, difficulty following conversations in noisy environments, poor school performance.
When to Refer to ENT/Audiology for Hearing Loss?
  • Failure in neonatal auditory screening.
  • Any suspicion of hearing loss in the consultation (see red flags). Early referral is key to language, speech and cognitive development!
  • Sudden hearing loss (urgency).
  • Persistent unilateral hearing loss (especially if it is sensorineural).
  • Conductive hearing loss that does not resolve (e.g. OME > 3 months).
  • Syndromes associated with risk of hearing loss (e.g. Down, Usher, Alport syndrome).

Common Dosages

Quick reference table for medications frequently used in pediatric ENT pathologies. Always verify doses with updated sources and according to the patient's weight.

Drug ENT Main Indication Pediatric Dosage (oral route) Frequency Grades
Paracetamol Analgesic/Antipyretic 10-15 mg/kg/dose Every 4-6h Max. 60-75 mg/kg/day
Ibuprofen Analgesic/Antipyretic, Anti-inflammatory 5-10 mg/kg/dose Every 6-8 hours Max. 40 mg/kg/day
Amoxicillin AOM, RSBA, GAS Pharyngotonsillitis 80-90 mg/kg/day Every 8-12 hours (2-3 doses) Max. 4g/day. Reduce dose in FARGAS (50 mg/kg/day).
Amoxicillin-Clavulanate AOM/RSBA (second line, failure), complicated sinusitis 80-90 mg amoxi/kg/day Every 12 hours (2 doses) Consider 7:1 presentations for less diarrhea.
Azithromycin Alternative to penicillin (allergy) 10 mg/kg/day (Day 1), then 5 mg/kg/day (Days 2-5) once a day For 5 days. Not for severe AOM.
Dexamethasone Acute laryngitis (croup) 0.15-0.6 mg/kg/single dose single dose Oral or IM. Reduces airway edema.
Mometasone Furoate (Nasal) Allergic rhinitis, adenoid hypertrophy 1-2 sprays/nose/day once a day Safe long-term use in children.

Clinical Pearls and Quick Tips

1. Otoscopy is key: In AOM, bulging and reduced tympanic mobility are more important than erythema alone.

2. The "mother's kiss" works: For nasal foreign bodies, it is a safe and often effective first-line attempt.

3. Pain: Always prioritize pain management in any ENT pathology. A child without pain cooperates better and recovers sooner.

4. Unilaterality: Purulent unilateral rhinorrhea or unilateral hearing loss should always make you suspect something else (foreign body, tumor).

5. Active listening: A delay in language or learning problems in preschoolers may be the only manifestation of hearing loss (OME).

6. When NOT to give antibiotics?: Common cold, OME (except complications), viral pharyngotonsillitis. Avoid antimicrobial resistance.

7. Hydration: Especially in pharyngotonsillitis and laryngitis, good hydration helps to thin secretions and relieve discomfort.

8. Smell also matters: Ask about the perception of smell in older children with chronic rhinosinusitis, it can be an important symptom.

Less frequent but important conditions

Periatonsillar abscess

Description: Complication of acute tonsillitis, formation of a collection of pus between the tonsillar capsule and pharyngeal muscles.

Symptoms: Very intense unilateral pain (odynophagia), lockjaw (difficulty opening the mouth), "hot potato" voice, deviation of the uvula to the contralateral side, fever. The boy looks very affected.

Refer URGENT: Suspected peritonsillar abscess.
Acute Cervical Lymphadenitis

Description: Inflammation and infection of cervical lymph nodes, common in children after viral or bacterial infection.

Symptoms: Palpable, painful, erythematous nodule, with fever and general malaise. Often unilateral.

Derive: Fluctuating nodule, persistent fever despite antibiotics, large size, suspicion of nontuberculous mycobacteria or malignancy.
Epistaxis (Nosebleed)

Description: Very common in children, generally anterior and self-limited.

Derive: Recurrent epistaxis despite conservative management, subsequent bleeding, suspected foreign body, facial trauma, or coagulation disorders.

When to Refer to ENT? (General Criteria)

In addition to the specific criteria mentioned in each section, consider referral to a pediatric otolaryngologist in the following cases:

Remember: Good communication with the ENT specialist is essential for continuity of care and the patient's well-being. Don't hesitate to contact them to discuss complex cases!