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.


This systematic review evaluates the scientific literature on abusive and non-abusive ear, nose and throat injuries published up until June 2021 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 2021 update includes two new studies on manifestations of physical abuse, a case report of a neonate with stridor and subcutaneous emphysema and a case series of nasal erosion as a sign of physical abuse.

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 is significantly associated with asphyxiation, either intentional or unintentional
    • 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.
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Original reviews and content © Cardiff University, funded by NSPCC
Updates and new material by RCPCH July 2021

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.

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