Ear, nose and throat: systematic review

Child Protection Evidence is a resource for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system.

Summary

This systematic review evaluates the scientific literature on abusive and non-abusive ear, nose and throat injuries published up until June 2024 and reflects the findings of eligible studies. The review aims to answer the following clinical questions:

• • What are the identified characteristics of epistaxis indicative of asphyxiation in children less than 2 years of age?
  • What are the ear, nose and throat manifestations of physical abuse or fabricated or induced illness?

The 2024 update includes four new studies on manifestations of physical abuse and fabricated illness. Two case series were included, one focussing on oronasal pressure injuries and another on neurotic excoriation injury as a sign of physical abuse. Two case reports were also included, one describing oesophageal perforation and a case of Munchausen by Proxy Syndrome.

Young children who present with epistaxis in the absence of direct trauma to the nose raises the possibility of asphyxiation. This finding has proved controversial, although a landmark study involving covert video surveillance identified that epistaxis was feasible following asphyxiation, however the precise association between the two has not been defined. Due to the significance of the findings, we aim to determine the probability of asphyxia from attempted suffocation for a young child presenting with epistaxis.

While injuries to the ear, nose and throat in children as a consequence of physical abuse or resulting from fabricated or induced illness are not a frequently described manifestation, they are nonetheless important to identify. As the head and neck are the most frequently targeted part of the body in physical abuse, it would seem likely that ear, nose and throat injuries will result from this.

Key findings:

• • Epistaxis is a rare presentation in children aged less than two years, however when present it may be associated with asphyxiation, either intentional or unintentional. In the absence of physical injury, consider other medical conditions
  • Some young children presenting with asphyxia may have no overt symptoms; those that were symptomatic included altered skin colour, respiratory distress, altered heart rate, and a possible history of Apparent Life-Threatening Events (ALTE)
  • Pharyngeal injuries (laceration and perforation) are the most frequently reported ENT injury, predominantly affecting neonates and infants who present with dysphagia, drooling, haemoptysis, and surgical emphysema
  • Ear injuries most commonly affect the external ear and include auricular deformity, abrasions, petechial lacerations, and burns
  • Fabrication and induction of ENT signs and symptoms most commonly involves recurrent unexplained otorrhoea or ENT lesions which fail to heal despite appropriate therapy.