Nasal injuries

Cite this article as:
Ragavan Navaratnam. Nasal injuries, Don't Forget the Bubbles, 2021. Available at:

13-year-old Freya (she/her) has been tackled in rugby and fell onto her nose. It bled initially and her mother has brought her as it is really swollen and looks wonky. “Is it broken, doctor?”

Nasal injuries in children are frequently encountered in paediatric emergency departments. One third of all nasal fractures occur in children, accounting for 60% of all facial fractures seen in the emergency department. The nose is the second most commonly injured site on a child and is more commonly seen in males. The most common locations of injury to the nose are: the nasal tip, the dorsum, and nasal root region with only 32% of injuries involving the nasal skeleton.

Nasal fractures are more common after three years of age, and unlikely below the first year of life, as the nasal bones are hardly ossified. But the bones aren’t the only thing you need to look out for; nasal obstruction and septal haematomas are important to identify and treat urgently.


Nasal trauma in children commonly arises following: falls, contact sports and automobile crashes, typically involving bicyclists or pedestrians. Non accidental injury also must be considered as a potential mechanism.

Important aspects of history should include:

  • mechanism
  • if there was any deformity immediately
  • new-onset nasal obstruction.
  • bleeding
  • anosmia

It is also important to note any previous nasal injury or pre-existing deformity.


Children with facial trauma are usually apprehensive, so any examination may be limited due lack of cooperation.  Pain relief and play therapy will go a long way. Bleeding and swelling often accompany injuries and can limit a thorough examination. Applying local pressure may be necessary prior to starting a formal examination.


The examination should start with inspection of the nose and the surrounding facial structures.  It is important to note:

  • Periorbital bruising in the absence of other orbital findings is suggestive of a nasal fracture.
  • External nasal deformity, epistaxis, oedema, and bruising is highly suggestive of a septal injury. Any deformity more be masked by swelling.
  • A flattened, broad nose with an increase of the inner canthal distance and associated with vertical orbital displacement is suggestive of a naso-orbito-ethmoid fracture. The normal mean inner canthal distance is 16 mm at birth and increases to 25 to 27 mm in the mature female and male face, respectively, although there is ethnic variation.

The intranasal cavity should be assessed with a nasal speculum to exclude a septal injury. A septal haematoma can arise without the presence of any external signs. The septum should be examined for the presence of fractures, displacement, lacerations, discoloration, and abnormal swelling. Don’t forget that the nasal septum may be acutely or chronically deviated so you may need to ask about this in the history. Sometimes looking at an old photo helps.

The key findings suggestive of septal hematoma include:

  • An asymmetrical septum with a blue/red discolouration
  • Swelling of the nasal mucosa that obstructs the nasal passage
  • The size of the mass does not change with the application of topical vasoconstricting agents.

Most times a septal haematoma looks like a blueberry up the nostril.


After inspection, the nasal bones should be palpated for tenderness, deformity, mobility and  crepitus, although realistically poking a bruised nose may be too painful to tolerate. It is important to note:

  • Tenderness over the frontal sinus may indicate frontal sinus fractures.
  • Tenderness to palpation of the tip of the nose may be suggestive of a septal hematoma
  • Tenderness and instability on palpation of the anterior nasal spine from beneath the upper lip may indicate a significant septal injury.
  • Malocclusion is suggestive of a midfacial Le Fort fracture.

It is important to exclude an associated skull fracture which may be indicated by the presence of clear fluid in the nasal cavity. A fracture through the cribriform plate can result in a CSF leak. In an ideal world you can test for beta-2-transferrin (present only in CSF, perilymph, and aqueous humor), but I have yet to hear of EDs which offer this.

The signs and symptoms of nasal septal injury may evolve during the 24 to 72 hours after injury. Children with nasal trauma should be safety-netted to return if anything changes after they go home.


A history and clinical examination should more than suffice in guiding the management of children with nasal injuries. In simple nasal injuries, imaging adds very little. Plain radiographs are of very limited benefit as the majority of the nose in children in cartilaginous and therefore poorly visualised on x-rays.

In injuries associated with more worrying features i.e. CSF leak or malocclusion, CT imaging is the modality of choice due to the risk of a Le Fort fracture or a base of skull injury.


A number of classifications systems have been proposed for nasal injuries. The first and most widely quoted was based on the pattern of injury sustained and the direction of force applied. More recently, a classification system based on pathological findings was proposed. This second classification system has been adapted, to incorporate clinical findings as opposed to the  pathologic patterning of injury.

Table showing 6 types of nasal injury
Classification of nasal injuries

A complicated fracture is classified as a Type II to Type IV  fracture with CSF rhinorrhea, airway obstruction, septal haematoma, crush injury, numbness, severe displacement or midface involvement.


The management of nasal trauma in infants and children depends upon their age, the degree of nasal obstruction, and associated injuries. Children with nasal trauma should maintain upright posture to prevent the formation and facilitate the resolution of any associated oedema and hematoma. Patients who have no symptoms, minimal swelling, and no septal deviation or hematoma do not need specific follow-up.  Ensure adequate analgesia is given and appropriate advice when to return (on-going bleeding, evolving nasal obstruction, worsening pain).

Epistaxis – Most acute nasal bleeds respond to direct pressure over the anterior nose. Encourage the child to pinch their own nose but if they are unable, asking a parent to perform this has the added benefit of helping reduce the patient’s anxiety. During simple compression, position the child upright and sit them forward. This will help avoid possible aspiration of blood. Distraction and play therapy during compression are useful. In the majority, bleeding is controlled within 5 – 10 minutes.

If direct pressure fails to control bleeding, a number of management options are available but are rarely needed in the emergency department. These include:

  • Nasal packing. Tamponading the bleeding point can be very effective but can be very distressing to children. Sedation is often required to facilitate the procedure. It is advisable to seek an ENT opinion before packing a child’s nose, especially if this is traumatic.
  • Topical vasoconstrictors. These can be very effective but are not without risks. They are most commonly used in the theatres by the ENT surgeons. Options include topical phenylephrine or oxymetazoline. After application of a vasoconstrictor, direct pressure should be applied for at least 5 minutes before reassessing for further bleeding.
  • Tranexamic acid.
  • Cautery. In the emergency department, chemical cautery is commonly used, predominately in the adult population. Typically 75% silver nitrate is used to arrest bleeding. Cauterisation is undertaken around the bleeding point. Cautery works most effectively on dry areas so direct cautery of a bleeding point is often unsuccessful until the surrounding area has been treated. Care must be taken to avoid the skin and it is paramount the child is calm and cooperative, which may necessitate sedation. Make sure you don’t cauterise both sides of the septum.

Children presenting with possible fractures or obvious deformity should be reviewed by an ENT specialist; generally this can wait a few days. In the very young, injuries resulting in nasal obstruction should be referred urgently as young children are obligate nasal breathers.

As mentioned previously, swelling and oedema can make an accurate assessment difficult. As such, an immediate referral of a child with a broken nose but no features of airway compromise may not be needed. Children can be referred to an outpatient clinic for review but should be seen within in five to seven days. Short delays in definitive management of up to a week have been shown to have little impact on long term outcome. However, delays over seven days can make reduction of fractures more challenging, largely due to the active growth centres in a child’s nasal bones promote rapid healing.

Potential complications of nasal injuries

A number of potential complications can arise as a result of nasal trauma, particularly if there is a fracture. The most common complication is obstruction. This is often due to either soft tissue swelling or a deviation of the septum following an injury. Persistent obstruction following an injury is more likely due to septal deviation and therefore requires assessment by an ENT surgeon.   

Poor cosmesis following healing is a common problem reported by patients and is a valid concern for many parents. Recent work has shown that those sustaining fractures at a younger age compared to those that had none, had no differences in functional outcomes but were likely to suffer with deviations of the septum, bumps or humps in the nasal bridge and saddle formation.  Ensuring a timely referral to a surgeon may help reduce the incidence of a poor aesthetic result for the patient.

A septal haematoma that is not promptly dealt with can result in a septal abscess or necrosis (and a future flat nose). Though infection can remain localised, cases of intracranial infection via tracking through the cavernous sinus have been reported. Cavernous sinus thrombosis is also a recognised complication of septal haematomas. Damage to the cribiform plate with a resulting CSF leak is also a potential avenue for intra-cranial infection.

Rarer complications but still clinically important include:

  • Lacrimal duct obstruction
  • Maxillary hypoplasia
  • Naso-oral fistula
  • Anosmia. If this occurs following trauma, it very rarely returns.

Take homes

A clever history and examination are key.

Ensure you examine the inside of the nose especially for a septal haematoma

Adequate analgesia and distraction will make examination much easier

Radiological investigations have little use in simple injuries.

Direct pressure for at least 10 minutes should stop most cases of epistaxis.

Make sure, if referring to clinic, the child is seen within a week.

You have examined Freya and she has no signs of obstruction, no septal haematoma and her bleeding as stopped. She does seem to have a deviated septum however, so you discharge her with advice for simple analgesia, safety-netted and referred her for rapid access ENT clinic within seven days.


Baek HJ, Kim DW, Ryu JH, Lee YJ. Identification of Nasal Bone Fractures on Conventional Radiography and Facial CT: Comparison of the Diagnostic Accuracy in Different Imaging Modalities and Analysis of Interobserver Reliability. Iran J Radio. 2013 Sep; 10(3): 140–147.

Beck R, Sorge M, Schneider A, Dietz A. Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int. 2018 Jan; 115(1-2): 12–22

Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A, Prulière-Escabasse V. Emergency Department care of childhood epistaxis. Emerg Med J. 2017;34(8):543

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Caglar B, Serin S, Akay S, Yilmaz G, Torun A, Adibelli ZH, Parlak I. The accuracy of bedside USG in the diagnosis of nasal fractures. Am J Emerg Med 2017 Nov;35(11):1653-1656.

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Elden LM, Potsic WP. Otolaryngology trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1663.

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How to interpret Rinne and Weber’s tests

Cite this article as:
Chiadika Uzor. How to interpret Rinne and Weber’s tests, Don't Forget the Bubbles, 2021. Available at:

Hearing loss in children may be due to a broad range of pathology. Early detection and management are essential for proper language and psychosocial development of children. Clinicians need to be able to to identify potential reversible causes and rule out more sinister conditions.

There are three main types of hearing loss: sensorineural, conductive and mixed. The former, sensorineural, although generally uncommon in children, is the main cause of permanent hearing loss in the paediatric setting. It results from a disturbance of the auditory pathway involving the cochlea of the inner ear, through to the brainstem. Conductive hearing loss typically occurs due to a disruption in the transmission of sound at the level of the external or middle ear. The most common cause of conductive hearing loss in children is otitis media with effusion, otherwise known as glue ear.

This article provides a clinical approach to assessing a child with hearing difficulty using Weber’s and Rinne’s tests and a guide to interpreting the examination findings.

But first, Sarah’s Story….

Sarah is 9-year-old girl who has just begun Grade 4. She is very excited to be back at school after many months of limited contact with friends amid the pandemic. Over the summer, her mum, Michelle, notices that Sarah has become more ‘absent’ and doesn’t seem to be hearing anything she tells her. This is concerning and out of the norm for Sarah who is usually very witty and quick to respond. Mum has noticed that the volume of the TV is higher and many times she has ignored the doorbell ringing (according to mum it’s impossible to miss the doorbell!). Following her attendance at the Parent-Teacher’s meeting where complaints are made about Sarah’s inattentiveness in class, consequently leading to her grades dropping,she decides she has to do something. Sarah has undergone numerous treatments for ear infections in the past with oral antibiotics and topical treatments as well. Michelle and Sarah got to their GP the following day. Otoscopy shows a very narrow external auditory canal, dermatitis and a milky discolouration of the external ear. The GP is concerned and feels that he has exhausted every treatment option and decides to refer for review in the Emergency Department. Sarah is generally well and has no other past medical or drug history. There is no known family history of deafness and Sarah does not swim.

Anatomy of the ear as it relates to hearing tests

The history and physical exam

The presentation of hearing loss differs depending on the age of the child. Auditory anomalies, in newborns, are exclusively picked up via universal screening programmes. In older children, the presentation is usually similar to Sarah’s story. They may have behavioural changes, delayed language skills or listen to the TV at a louder volume than everyone else. These are often picked up by their teachers. It is important to ascertain whether there are other associated otological symptoms including otalgia, otorrhoea, vertigo or tinnitus. A thorough history should be obtained. This includes asking about other neurological symptoms, background medical history (including a thorough medication history), and possible precipitating events such as recent viral infection, trauma, or commencement of a new medication.

The tuning fork tests

Weber and Rinne tests are reliable and useful tools for assessing hearing loss in older, verbal children. They help distinguish between conductive and sensorineural hearing loss and so are more useful in patients with unilateral hearing difficulty. Children with mixed, or bilateral hearing loss, should be referred to an ENT specialist for a more formal pure tone audiometry assessment. It doesn’t matter which test you perform first. These tests should, however, be performed with a full cranial nerve and neurological exam.

How do I do Rinne’s test?

Before you begin the exam, it is important to explain to the child what you are about to do to in way they can understand. Try to put them at ease and make sure they are sitting comfortably, ideally in a silent room. Ask about pain especially over the mastoid.

Rinne’s test aims to compare air conduction with bone conduction. In a normal situation, air conduction is greater than bone conduction.

  • Begin by striking a 512 Hz tuning fork against your knee or elbow.
  • Place the base against the patient’s mastoid process (for those who like to watch it on a video, check one out here)
  • Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of the sound then promptly raise the fork off the mastoid process and place the vibrating tips about 1cm from their external auditory meatus
  • Leave it there for a few seconds before taking the tuning fork away from their ear
  • Ask the child whether the sound was louder at the beginning (when it was held against their mastoid) or whether it became louder (when it was held in front of their ear).

How do I interpret Rinne’s test?

In a normal ear, air conduction is greater than bone conduction. Air transmits sound to the cochlea more efficiently than bone. A patient who hears the tuning fork loudest when it is placed 1cm from the external auditory meatus has a positive Rinne’s test and a person who hears loudest when placed over the mastoid process has a negative Rinne’s test. The challenge in making these interpretations is in the case of a false positive Rinne’s test where there is unilateral sensorineural hearing loss. This is where Weber’s test is most useful in providing further clues.

How do I do Weber’s test?

  • As in Rinne’s test, begin by striking the 512 Hz tuning fork against your knee or elbow
  • Then, place the base of the fork in the midline, high on the patient’s forehead
  • Ask whether they hear the sound in the midline or if the sound lateralises to either the affected or good ear.
  • If the child is unclear, then ask if they hear the sound everywhere – be careful not to ask in a leading manner.
How to interpret Weber's and Rinne's test

How do I interpret Weber’s?

If a patient has a unilateral sensorineural hearing loss, the sound will lateralise – move to the good ear. If a patient has unilateral conductive hearing loss, the tuning fork sound would be heard loudest in the affected ear. Where hearing loss is bilateral and symmetrical of either type, Weber’s test would be normal. 

The table below summarises the outcomes of Rinne’s and Weber tests

How to interpret Weber and Rinne's test
AC = air conduction; BC = bone conduction

Differential diagnosis

Sarah presents to the Emergency Department and mum narrates the story to the attending doctor. Her right ear appears to be the troubling ear and she is experiencing mild pain on that side. The doctor proceeds to perform a focused ENT exam. He begins with otoscopy and notes that there is unilateral, right-sided narrowing of the external auditory canal secondary to oedema The overlying skin is milk coloured, resembling candida infection. Her left ear is impacted with cerumen but otherwise looks normal. Using a 512 Hz tuning fork, he performs Weber and Rinne’s tests. Rinne’s test demonstrated unilateral right-sided negative result i.e. bone conduction is greater than air conduction in the right ear. There is lateralisation of the tuning fork sound to the left ear on Weber’s: Sarah has reduced hearing in her right ear due to conductive hearing loss likely secondary to fungal otitis externa. The rest of her ENT exam is normal, and she is neurologically intact. The doctor explains to mum that Sarah most likely has a fungal infection of her outer ear and will require a trial of anti-fungal ear drop for 2 weeks. He also prescribes a short course of topical steroid ear drops to reduce the swelling and recommends oil drops for the impacted left ear, telling Michelle to return to her GP if Sarah has further issues with her hearing in the future. He reassures mum that a formal auditory test is not required at this time until the treatment is completed.

Selected references on interpreting Weber’s and Rinne’s

Dimitrov L, Gossman WG. Pediatric Hearing Loss. [Updated 2020 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

 [dh1]Andy, I don’t think this image has a Creative Commons license. Do you want to create a new one? Or use a wiki one? There are some free to use ones without labels if you want to use Montserrat here

 [dh2]This is definitely not free to use. Do you want to make a new one Andy?


Cite this article as:
Miran Pankhania. Epistaxis, Don't Forget the Bubbles, 2020. Available at:

Epistaxis is common and affects >10% of us in our lifetimes. Children present with epistaxis for a number of reasons, many different to adults. Unfortunately, physics underpins most of these causes.

The nose is a very vascular part of the head and neck, owing to its function in humidifying air as it is breathed in. The nasal mucosa becomes engorged in response to dryness and low temperatures to make air more comfortable to breathe in. This response is more noticeable in patients who are ethnically extracted from tropical and equatorial climates.

Sagittal view of nose showing blood supply of inner aspect
Anatomy of the nasal vessels

The arteries contributing to the blood supply of the nose include:

Anterior and Posterior Ethmoid arteries – branches of the Internal Carotid artery

The Superior Labial, Sphenopalatine, and Nasopalatine arteries – branches of the External Carotid artery.

These aren’t necessarily directly relevant to the management of paediatric epistaxis but do become important in some very special circumstances.

These arteries form a plexus in Little’s area called Kiesselbach’s plexus – Conveniently located approximately as far as a person can put their index finger inside their nostril.

Nose picking

The most common cause in children, but surprisingly common in adults too. Look for the tell-tale white keratinised patch inside the nostril, almost invariably on the anterior septum, at Little’s area. Nose picking can directly traumatise a vessel or can cause turbulent flow over an area, drying out the septum and increasing the risk of bleeding.


Common airborne allergens, such as house dust mite faeces, grass and tree pollen, and animal antigens eg cat saliva and dog hair can cause a Type I hypersensitivity reaction in the upper airways. This results in further engorgement of the nasal mucosa and can make already fragile vessels bleed, again by increasing turbulent airflow through the nose.

Idiopathic – Most people have a deviated nasal septum to some extent. Non-laminar flow over a deviated nasal septum can differentially dry out one side compared to the other and result in epistaxis.

Blunt force trauma

To differentiate this from simple nose picking, we need to consider a mode of injury which, although more common in adults through falls or assault, is also seen in children who fall whilst playing, or as a result of non-accidental injury. Blunt force trauma can result in arterial bleeding from the anterior ethmoid vessels and may be associated with other facial injuries. Acute manipulation of the bones can stop significant bleeding but sometimes an inspection of the nose under general anaesthetic is also needed to identify a bleeding point.

Rare causes

Epistaxis can rarely be the first presentation of haematological disease through derangement of clotting, for example, in leukaemia, lymphoma, or haemophilia. Beware the adolescent male who presents with torrential bleeding and unilateral nasal obstruction, who may have a rare vascular tumour centred on the sphenopalatine artery  – a juvenile nasal angiofibroma – which accounts for 0.05% of all head and neck tumours. Whilst benign, they are locally aggressive and in advanced disease, they can involve the internal carotid artery.


Very rarely, children undergoing oncological treatment may develop mucositis which can affect their nose. This, in conjunction with thrombocytopaenia and nasal cannulae, NG tubes, and turbulent airflow can cause a very difficult to treat epistaxis. ENT may use Floseal – a haemostatic semi-solid matrix made of human recombinant thrombin. Do not pack or instrument the nose as this will cause more bleeding.

Clinical Assessment

General inspection

Check for signs of distress, anaemia, pallor, cachexia, and lymphadenopathy.

Nasal examination

Check for signs of bleeding – Is this unilateral or bilateral? If you have a cold metal spatula, hold this under the nose to see if it mists equally assuming the nasal cavities are clear of blood. Evert the tip of the nostril to examine the nasal vestibule. You should be able to see the septum in the midline and the inferior turbinate laterally on either side. The colour of the inferior turbinate can give you an idea as to underlying pathology – a bluish, oedematous turbinate suggests venous congestion and is seen in allergy.

Oral examination

The posterior nares open into the nasopharynx, behind the soft palate and uvula. Before and after any nasal intervention, check the posterior pharyngeal wall with a good headlight and tongue depressor to see if there is blood still trickling down the pharynx or not. In drowsy or obtunded patients, this can pose a risk of aspiration.

No active bleeding?

Good news. The bleeding has probably stopped but might start again. You can inspect the nostrils with an otoscope with a speculum on it. This magnifies and the lens can also be slid aside to allow you to insert a silver nitrate stick through it if you’re able to see a point to cauterise – don’t do this without some form of topical anaesthetic as it causes a chemical burn which…well…burns! Some departments have 1% lidocaine spray but this can also sting as it hits the mucosa so ideally squirt it onto some cotton wool with some 1:10000 adrenaline before applying it to the nose for 5 minutes then remove it prior to cautery. If you don’t know how to cauterise, don’t worry…a Cochrane review found that emollients such as Vaseline or Naseptin ointment were as effective as silver nitrate cautery in stopping paediatric epistaxis. You’re just as likely to succeed by making an outpatient referral to ENT and prescribing some emollient for intranasal use 3-4 times a day until reviewed. Make sure they don’t try to rub it in with their finger or a cotton bud. Simply insert the tip of the nozzle into the nostril, squirt, pinch the nostrils together, and sniff.


So you’ve got an active bleeder?! Worry not…anxiety is contagious so it’s important to stay calm for both your sake and the child and their parents.

Sit the child upright, attach monitoring, and raise the bed so you don’t injure your back. Get PPE on. This means gloves, apron, goggles, and a mask. Meanwhile, ask someone, if not the child, to pinch the soft part of their nose whilst tipping the head forward. Do this without letting go for 10-15 minutes. This prevents aspiration and compresses the septum which is where the bleeding is likely to be coming from. Assess the airway, breathing, and circulation as you would for any other emergency patient.

Get hold of cotton wool balls, 1% lidocaine, and 1:10000 adrenaline. If you happen to have pre-mixed 5% lidocaine with 0.5% phenylephrine, this is even better. Make some pea-sized balls with the cotton wool and soak in the anaesthetic and adrenaline mixture. Gently place inside the offending nostril(s) and wait. This will buy you time and allow you to coordinate the rest of your care.

Use this time to ask yourself some questions.

Do I need to cannulate the child? (Probably not)

Where is the ice kept? Fill a glove with some ice and place over the forehead or pop a cube inside the mouth to aid vasoconstriction and stimulate the diving reflex – this will reduce the cardiac output a little and facilitate haemostasis.

Do we have silver nitrate and do I know how to use it?

Do I need to pack the nose?

Do I need to call ENT?

Reassess ABC

When should I refer to ENT?

  • Heavy bleeding
  • Heavy bleeding in the presence of trauma
  • Recurrent epistaxis
  • An adolescent male with unilateral nasal obstruction and torrential bleeding

Children with JNAs ultimately go to the operating theatre for resection of the tumour endoscopically. They will also have pre-operative embolization. This can be done for the sphenopalatine branch but there is a risk of stroke and blindness if the branches of the internal carotid are inadvertently embolised.

Some common pitfalls:

Not using anaesthetic – this is one of the most common failings and is very unpleasant for an already traumatised child.

Cautery – It’s great when it works, however, silver nitrate dissociates into nitric acid and silver hydroxide on contact with water. The nitric acid burns anything it comes into contact with so after cauterising, place some cotton wool inside the nose to soak up the excess. Similarly, the silver hydroxide can also dribble down the nose and cause an unsightly but temporary black tattoo.

Naseptin – This contains chlorhexidine and arachis oil. Whilst the arachis oil is boiled to sterilise it, caution should be taken in those with severe peanut allergy in case of anaphylaxis. Chlorhexidine is similarly allergenic – 2% of healthcare workers are sensitive to chlorhexidine, and 0.2% of the general population.

Cuffed or uncuffed tubes?

Cite this article as:
Tessa Davis. Cuffed or uncuffed tubes?, Don't Forget the Bubbles, 2018. Available at:

The debate over uncuffed versus cuffed endotracheal tubes (ETTs) is a long-standing one. In a paper published in Pediatric Anesthesia this week, one paediatric critical care unit has published the results of their experience of introducing cuffed ETTs.

Greaney D, Russell J, Dawkins I, Healy M, A retrospective observational study of acquired subglottic stenosis using low-pressure, high-volume cuffed endotracheal tubes. Pediatric Anesthesia, 2018, DOI: 10.1111/pan.13519


What’s the background?

Many intensive care units use uncuffed ETTs in neonates due to concerns of cuff-related trauma and subglottic stenosis. The estimated incidence of ETT-related subglottic stenosis (SGS) ranges from 0.3-11%.

The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring, protection from aspiration, fewer tube changes due to air leaks, and continuous lung recruitment.

The concerns about cuffed tubes are that they cause increased trauma and that this trauma can lead to erosion, infection, cricoid perichondritis, and ultimately sub-glottic stenosis.

The author introduced the use of Microcuff ETTs into their unit hypothesizing that it may lead to less ulceration, chondritis, and fibrosis in the subglottic space. Microcuffs are a specific type of ETT (low-pressure, high-volume), but the smallest type is 3.0mm internal diameter which is not recommended for neonates less than 3kg.


Who were the patients?

This was a retrospective analysis of all patients admitted to the Paediatric Critical Care Unit in Australia over a five year period.

Patients were included if they also had a microlaryngobronchoscopy (MLB) procedure.

Patients were excluded if they were >18 years old; had congenital SGS; had previous airway surgery, or had a previous SGS diagnosis.


What were the outcomes?

MLB reports were reviewed to look for findings consistent with clinically significant acquired endotracheal tube-related pathology (within six months of intubation).

Demographics were analyzed including age, sex, prematurity, comorbidities, duration of ventilation, number of intubations, duration of admission.


What did they find?

There were 5309 PCCU admissions over the five year period, and 61% required intubation.

297 patients had an MLB.

23 children (0.68% of all intubations) had a clinically significant ETT-related pathology: 8 had acquiredsub-glottic stenosis; the other 15 had other ETT-related pathology (granulomas, ulcers, or cysts).

5 of the 8 children with sub-glottic stenosis required tracheostomies.

All those who required surgical correction of the SGS were ex-prem neonates who had received invasive ventilation in a NICU with an uncuffed tube prior to admission to PCCU.


What conclusions did they draw?

They demonstrated a low incidence (but high morbidity) of acquired SGS.

There were a few issues around the conclusions drawn:

  • The authors state ‘there was no single case of de novo clinically significant acquired SGS with the use of cuffed ETTs‘. I’m not sure that this is a fair conclusion, as there were 8 cases of acquired SGS. Yes, these cases all had an uncuffed tube initially in NICU, but they also had a cuffed tube in PCCU.
  • It would be good to be able to compare the rates of SGS before the introduction of Microcuff ETTs with these rates after its introduction – this would help to see whether rates have increased. It would also be helpful to look at the neonatal group in particular as this study reports the overall percentage of SGS in all patients, and then draws conclusions about its safety in neonates.


However, in spite of concerns around the use of cuffed tubes that exist, no study has previously shown that cuffed ETTs lead to a higher incidence of SGS than uncuffed ETTs. This is an interesting paper to open the discussion around the use of cuffed ETTs in neonates.

If you want to learn more about tiny tubes then catch this talk from Shabs Rajapaksa from DFTB18.


Expert Opinion – Eric Levi, Consultant Paediatric Otolaryngologist

I would love to see other data to enhance this paper: comparison with rates of SGS prior to cuffed tubes and comparison of rates of SGS in other patients who did have an uncuffed tube but did not develop SGS. Surely in the 3000 or so intubations, there would have been others who were also tubed with uncuffed tube and yet not develop any tube related pathology.

Although this is not a perfect paper, I do think the authors are onto something, and that they are adding to the body of knowledge suggesting that in their cohort, cuffed tubes are not associated with SGS.

Crash course in tracheostomies

Cite this article as:
Tessa Davis. Crash course in tracheostomies, Don't Forget the Bubbles, 2017. Available at:

It’s 2am and the crash bleep goes off. You arrive at the bedside of 5-year-old Jerry who has suddenly dropped his sats to 80%. He looks like he has a tracheostomy tube in his neck. Can you keep your cool and handle it like a pro?

Thanks to the team at for their support in writing this post. Much of the content is a summary of all the wonderful learning resources on their website and also from their library of  videos. This post has been updated in Oct 2020 since it was originally written in 2017. Thanks also to Miran Pankhania (ENT Surgeon in Rotherham, UK) and Eric Levi (ENT Surgeon in Melbourne, Australia) for input. 

This update recognises the key differences between paediatric and adult tracheostomy emergency management.

-Paediatric bed signs showing the reasons for the tracheostomy and the type
-Tracheostomies in children are almost all surgical and have stay sutures and maturation sutures which help with emergency management
-In emergency management, have three attempts to change the tube before moving onto oral intubation
-On the third tube reinsertion attempt, use a suction catheter as a guide to insertion.

Do you know the difference between a tracheotomy, a tracheostomy, and a laryngectomy?

Tracheotomy – an incision in the trachea

Tracheostomy – a stoma in the trachea (i.e. an opening which has been created)

Laryngectomy – surgical removal of the larynx – tracheal remnants are stitched to the anterior tracheal wall and there is no connection from the mouth and nose to the rest of the airway. This is almost exclusively an adult procedure though.

Tracheotomy or tracheostomy patients potentially have two airways but a laryngectomy patient only has one.

Which does Jerry have?

It’s very hard to tell by looking at the patient which they have, and hospital inpatients will have a sheet above their bed making it clear which type they have, what pathology they have, and why they have the tracheostomy.

The key things you need to know are:

  • is there a connection between their mouth/nose and their lungs? (i.e. 1 or 2 airways)
  • are they known to have a difficult airway?
  • how old is the tracheostomy and what was the procedure to make it?

A surgical tracheostomy is made by making an incision in the neck and stitching it open – this type of approach will create an established tract. A percutaneous tracheostomy just stretches the skin back to make the stoma and so it more likely to close in 7-10 days if not kept patent.

Why do kids need tracheostomies?

  • Bilateral vocal cord palsy with decompensation
  • Subglottic or laryngeal stenosis​/atresia
  • Tracheoesophageal cleft/fistula
  • Respiratory toilet and airway protection
  • Long term ventilation
  • Covering for airway surgery – laryngotracheal reconstruction or as part of EXIT procedure
  • Covering for an extra-luminal mass

Do you know your anatomy? has fabulous eLearning resources that goes through the anatomy in more detail. But for now, we can recognise our major landmarks…

How is a tracheostomy created?

The trachea is entered by making a cut in the anterior tracheal wall at the level of the 2nd or 3rd tracheal cartilage.

Tracheostomies in children are usually open surgical procedures to minimise the risk of hypoxia from accidental decannulation. Whereas tracheostomies in adults are usually percutaneous procedures.

The child’s neck is fatty by comparison to an adult neck, so the subcutaneous fat is often removed to make the trachea as close to the skin as possible in the event of accidental decannulation.
Stay sutures are put in the tracheal wall (akin to parachute cords) to bring the tracheotomy to the skin and open it in case of decannulation.
Maturation sutures are from the tracheotomy to the skin to align all the holes made and minimise risk from decannulation and facilitate re-intubation of the stoma.


What could have gone wrong with Jerry’s tracheostomy?

Complications of tracheostomies are split into peri-operative, early postoperative, and late post-operative

Peri-operative: haemorrhage; misplaced tube; pneumothorax; tube occlusion; surgical emphysema

Early post-operative (<7 days): tube blockage; tube displacement; site infection; lung infection; tracheal ulceration; fistula; haemorrhage

Late post-operative (>7 days): granuloma; tracheal collapse; blocked tube; haemorrhage; tracheal stenosis

What are the different types of tubes?

Shiley do Neo and Ped trachy tubes are the main types. These are single lumen plus or minus a cuff (depending on the indication for insertion).

Paediatric tracheostomy tubes are usually uncuffed with no inner tube. This is because the trachea has a small diameter, and an inner tube would reduce that even further. Cuffed tubes can be used in cases where high pressures are needed or these is a risk of aspiration.

If a patient has an uncuffed tube, that patient has no airway protection from aspiration, but air can flow through the mouth and nose and down past the tube.

If a patient has a cuffed tube, that patient’s airway is protected from aspiration, but the tracheostomy is the only route for airflow (which is a problem if the tube becomes blocked). If you deflate the cuff, air can flow from the mouth and nose down the trachea.


Tracheostomy tubes come with lots of different additions. Most of these are  Heat-Moisture Exchanges e.g. the Swedish nose. These help maintain humidity (like a real nose). During normal breathing, air is warmed, filtered and moistened by ciliated epithelial cells in the nose and upper airways. However, this does happen with a tracheostomy tube and so air inspired will be cold and dry. The HMEs conserve heat and moisture on expiration.

Now we have a good understanding of the anatomy and types of tracheostomies, how are we going to help Jerry?

Follow a step-by-step approach to managing tracheostomy emergencies.

1. Call for help (anaesthetics or ENT).

Establish how many airways we have to work with. Has Jerry had a laryngectomy (one airway) or a tracheostomy (two airways)? Look for a sign around his bed.


2. Look, listen, and feel at the mouth and the stoma.

Is the patient breathing? If not then consider airway positioning (depending on the age of the child).

In real life, many time where there are desaturations and difficulty ventilating, it is due to either clots or mucous plugging, or due to positioning (i.e. tracheostomy tube is too short and ends up hitting back wall of trachea, or too long and ends up in one bronchi). Extending the neck/shoulder roll and suctioning the tube vigorously may help resolve lots of common obstruction.

Jerry is breathing, but if he wasn’t we would check a pulse and follow the APLS algorithm. He has a tracheostomy with an uncuffed tube.

3. Apply high flow oxygen

Apply to the mouth and nose (if the patient has two airways, which we now know Jerry does) and to the tracheostomy.  This will require two oxygen sources.


Then think about some common tracheostomy problems:

  • Remove any attachments e.g. speaking valve or caps
  • Remove the inner cannula if there is one (although not common in younger children)

  • Assess patency by putting a suction catheter down (this is better than just bagging first because if the tube is dislodged you will cause surgical emphysema by bagging). If you can pass the catheter then you should suction and ventilate if they are not breathing.

You try to pass a suction catheter down Jerry’s tube, but you cannot pass it.

If you can’t pass the catheter then the problem is that the tracheostomy is blocked and it’s time to problem solve.

4. Do an emergency tracheostomy tube change

Jerry needs and emergency tube change. This is a key difference in children as Jerry will have maturation sutures – so this should be attempted before upper airway management. You need to cut and remove any tapes and aim for immediate reinsertion. If there are stay sutures then lift them up and out by hand.

Try to put one of the same size in again. No bougie, wire or catheter is recommended. An obturator can help guide insertion and protect the stoma. If it goes back in then check it is patent and assess again by look, listening, and feeling at the tracheostomy and mouth/nose (and reapply oxygen). Some gentle ventilation can be attempted if there are no spontaneous respiration efforts. Don’t attempt to ventilate if the suction catheter won’t pass – you do not want to cause subcutaneous emphysema if the tube is in a false passage.

5. Try a second emergency tracheostomy tube change

Try again with a tube a half-size smaller. Consider changing the position of the child to bring the trachea anteriorly.

Try oral airway manoeuvres by covering the stoma with gauze or your hand and: bag-valve-mask; oral or nasal airway adjuncts; or an LMA.

6. Try a third emergency tracheostomy tube change with a suction catheter

If this second attempt doesn’t work, then try a third attempt. This time use a soft suction catheter as a guide for your tube to go over (like the Seldinger technique). Also use a half size smaller than the original tube (same size as the second attempt).

You have removed the tracheostomy tube but Jerry is still not breathing (he has a pulse). You cannot replace the tube on your first three attempts.

7. Go for emergency oxygenation

Try oxygenation with the mouth (via bag-valve mask) or with a supraglottic airway. If this isn’t working then try via the stoma with a bag-valve mask over the stoma, or an LMA over the stoma.

If you aren’t able to ventilate Jerry with these basic maneouvres. It’s time for something more invasive.

8. Attempt oral intubation

Attempt oral intubation, but prepare for a difficult intubation and make sure your ETT passes the stoma.

9. Attempt intubation of the stoma

Attempt intubation of the stoma itself using a tracheal tube a half-size smaller than the previous tube. There is a risk of blindly intubating a stoma as you may create a false tract. If you have someone (or are someone) with more experience, you can put your finger into the trachea and guide the bougie, or use a fibre-optic technique.

10. This is a CICO situation

At this point you need to declare a CICO. Attempts should be made by more experienced staff, or emergency front of neck access will be required. Remember though that a tracheostomy is the quintessential FONA. If the tracheostomy tube fails, either a significant false passage, complete obstruction, or distal pathology at the level of the carina & bronchi has occurred. Definitive means to salvage this situation is tricky and may involve the urgent use of a flexible or rigid tracheobronchoscopic assessment to visualise the distal pathology.

Thankfully using a face mask over the stoma works and Jerry picks up just as the Anaesthetic Consultant arrives.

If you want a nice summary with Sheila rather than Jerry – then watch this fabulous video of the emergency tracheostomy algorithm.

Selected references:

The Association of Anaesthetists of Great Britain & Ireland grants readers the right to reproduce the algorithms included in this article (Figs 1 and 2) for non-commercial purposes (including in scholarly journals, books and non-commercial websites), without the need to request permission. Each reproduction of any algorithm must be accompanied by the following text: Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd.

Check out for more resources on this topic and read the paediatric tracheostomy emergencies guideline here:

Ears looking at you, kid

Cite this article as:
Andrew Tagg. Ears looking at you, kid, Don't Forget the Bubbles, 2016. Available at:

Earache is a leading cause of grumpiness in children.  A recent paper in the New England Journal of Medicine has suggested that a 10 day course of antibiotics is more effective than a 5 day course in treating acute otitis media and, as such, should be considered in infants under 2 years with otitis media. But is this right?

Can’t intubate, Can’t Oxygenate

Cite this article as:
Andrew Tagg. Can’t intubate, Can’t Oxygenate, Don't Forget the Bubbles, 2016. Available at:

Paediatric critical procedures are rare in the emergency department. Data from one Victorian network showed that 83% of emergency physicians had not performed one in a twelve-month period. We also know from audit data that we seem to have a lower first-pass success rate (around 78%) when it comes to paediatric intubation. We can put in a lot of strategies to increase the chance of first-pass success but what happens if you get into a ‘Can’t Intubate, Can’t Oxygenate” (CICO) scenario?

Those of us that look after adults as well as children have a standard response to the CICO scenario using an established algorithm whether it is the Vortex approach or the DAS guidelines.  They all end up with a puncture of the neck (be it via scalpel or needle). What approach should be undertaken in children?

[Editors note: At this point it is worth remarking that children are not heterogenous creatures and your approach to an unimmunized 2 year old with nasty epiglottitis is very different from the 12 year old who has tried to inhale a never-ending gobstopper.]

Stefano Sabato and Elliot Long, both from the Royal Children’s Hospital, Melbourne have reviewed the evidence and tried to answer the question in this article:

Sabato SC, Long E. An institutional approach to the management of the ‘Can’t Intubate, Can’t Oxygenate’ emergency in children. Pediatric Anesthesia. 2016 Jun 1.

How common is the scenario?

The true number of CICO scenarios that occur in a paediatric setting is unknown. There were 13 major complications reported in the NAP4 dataset, representing 7% of all reported cases. Only five of these required a surgical airway. This is likely to be an under-representation of true events. Regionalisation of paediatric care and lack of resident ENT staff in the UK may have lead to intensivists/anaesthetists having little experience in managing sick children.

Some of the potential risks

  • Failure to use capnography to confirm tube placement
  • Failure to adequately secure the tube once in place
  • Management of airway compromise during patient transfer

The incidence of failed intubation (defined as more than three attempts to get the tube through the cords) in healthy kids is around 0.08% rising to 0.24% in infants less than a year old.

Predicting the difficult airway in children

Anecdotally, there has been little emphasis on formal airway assessment in children with the majority of standard tools not validated in the paediatric population. Even when performed in adults an airway assessment might not reduce the risk of the unanticipated difficult airway.

Common sense would suggest that if a child has a history of sleeping issues, perhaps due to adenotonsillar hypertrophy, they may be more likely to obstruct on induction. Looking at the child you might spot drooling or mouth breathing that occurs with enlarged tonsils or upper airway obstruction. Congenital abnormalities or dysmorphic features such as micrognathia in the Cri du Chat sequence or glossomegaly in trisomy 21 can also make intubation a challenge.

Formal airway assessment should include:

  • Mouth opening
  • Assessment of dentition for loose or protruding teeth
  • Tongue size
  • Presence of soft tissues mass in the mouth?
  • Mandible size
  • Neck mobility
  • Tempero-mandibular joint (TMJ) mobility

The Mallampati score is impractical in children as they have a tendency not to do what is required, especially when scared and Kopp et al (1995) found it to be a poor predictor of glottic view.

Needle versus Knife?

Whilst a formal tracheostomy by a qualified ENT surgeon would be fabulous, most of us don’t have Dr Eric Levi on speed dial. The options seem to be split between the ‘knife‘ (a scalpel based approach) or the ‘needle‘  (a narrow or wide bore cannula or formal needle cric set).

The Knife

If you look after adults as well as children you should be familiar with the scalpel-finger-bougie technique so I won’t go into the details. The 4th National Audit Project  from the Royal College of Anaesthetists in the UK suggested that a scalpel technique was preferable to the alternatives unless practitioners were more experienced in alternative techniques. Failure to commit to a ‘surgical’ airway in a timely fashion was highlighted as a key issue.

So why can’t we do the same with children?

Sabato and Long remind us that we are dealing with extremely small targets.  The neonatal cricothyroid membrane is only about 2.6mm in length and 3.0mm in width. That is smaller than a grain of rice!

The CTM in a neonate is smaller than a grain of rice - an near impossible target in CICO

Identifying the appropriate anatomy will become easier as we become more proficient with the use of bedside ultrasound to identify landmarks.

The Needles

The authors of the article recommend a needle based approach using as shallow an angle of approach as possible (with extension of the neck to expose the cricothyroid membrane) to avoid transfixing the trachea by puncturing the posterior wall.  There are a number of commercial kits available but poverty of choice is important. Should a CICO situation arise the last thing you need to be worrying about is which kit to use. A 16g cannula based kit is their recommendation. Children die because of a lack of oxygenation not a lack of an airway. The goal is to provide adequate oxygenation until expert help arrives.

For more on the various devices available then read this excellent article.

So what should we do?

Call for help early and get your friendly ENT surgeon involved. If that is not an option then the authors recommend a needle-based approach for front of neck access. They give examples of the kit used at the Royal Children’s Hospital. You can see the kit here. Being aware of the principles is one thing but like all emergencies, we have to be prepared to perform when the time comes. Mental rehearsal of your preferred technique helps, as does using part trainers or practice in the animal lab but they do little to help one overcome the fear of performing the procedure. When intubating adults I use a checklist and call out my failed intubation plan, ending with a check of my surgical equipment. I must admit to having been more blasé about doing the same for paediatric intubations. This will no longer be the case.

How should you do it?

The Difficult Airway Society suggest the following approach:-

  • Extend the neck (making the target as big as possible)
  • Stabilize the larynx with the non-dominant hand
  • Access the cricothyroid membrane with a dedicated 14/16g cannula
  • Aim in a caudal direction
  • Confirm position with aspiration of air into a syringe containing saline
  • Connect to an oxygen source
  • Slowly increase inflation pressure/flow rate to achieve maximal chest rise
  • Maintain upper airway patency to aid expiration

DAS recommend following adult guidelines once the child is over the age of eight. Needle cricothyroidotomy is not without risk and though it may be successful on the first go in up to 70% of cases there is a high risk of perforation of the posterior wall of the trachea. Trans-tracheal cannulation is not a failure of the technique if oxygenation is maintained.

Perhaps the easiest way to connect to an oxygen source is to attach a 3mm ETT tube connecter.  You then have a universal 22mm connector to attach to your circuit.

How do we train for it?

Cliff Reid has written in the past about using the greatest piece of virtual reality hardware there is – the brain – to prepare for such a rare event. There are part task trainers for adult practice but I challenge the readers to find one for use in paediatric practice.

The first key step is reducing the risk of it happening in the first place through proper training and preparation. More than two attempts at tracheal intubation is associated with an increased risk of complications and each further attempt incrementally increases the risk. Techniques such as the use of video laryngoscopes and optimum pre-oxygenation and apnoeic oxygenation may modify some of the risks but sometimes there is no accounting for anatomical variation.

Of course the title of this article is taken from the amazing Neil Young, and is about a very different type of needle.

With thanks to @NicholasChrimes, @DrEricLevi, @airwaycam, @DitchDoc14, and especially @kovacsgj


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ENT Part 3: a frog in your throat?

Cite this article as:
Tessa Davis. ENT Part 3: a frog in your throat?, Don't Forget the Bubbles, 2016. Available at:

Here is the third part in our three part ENT series looking at recognition and management of common paediatric ENT conditions. This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Part 2 was on – the nose. Today, we look at the throat.