Transcript Document
When to refer to ENT: Lumps, bumps, and others.
David J. Brown, M.D.
Associate Professor Division of Pediatric Otolaryngology Interim Associate Vice President and Associate Dean for Health Equity and Inclusion
Epistaxis
Proper technique of stopping nose bleeds
Nasal blood vessel anatomy
Nose bleed maintenance
• Keep moist – Humidifier – Nasal saline – Ointment along septum • Keep fingers out of nose • Trim fingernails • Can refer if these measures don’t work, significant bleeding, and/or parents want to consider nasal cautery
Juvenile nasopharyngeal angiofibroma
• In males • Usually teenage • Extensive bleeding • May have nasal obstruction • May have CN V sensory deficits
Congenital Nasal Masses- Dermoid
Midline nasal masses
• Dermoid • Glioma • Encephalocele • • May extend intracranial Therefore, NEVER biopsy or cut open before obtaining a scan.
Parotitis
Congenital and Vascular Anomalies
• Branchial cleft cyst • Thyroglossal duct cyst • Laryngocele • Hemangioma • AVM • Lymphatic malformation
Hemangioma
• Beard distribution has high risk of subglottic hemangioma • High likelihood of having airway issues • May need a trach
Congenital Anomalies Thyroglossal Duct Cyst
Branchial Cleft Anomalies Second most common head and neck congenital lesion 20% of congenital cervical masses in children 1% are bilateral Thought to occur secondary to incomplete obliteration of the branchial clefts and pouches during embryogenesis Second: 40-95% First: 5-25% Third/Fourth: 2-8%
Case 4 yo girl presents with postauricular mass.
Had been infected twice and I&D performed at OSH ED PE: Post-auricular non-tender cystic mass. DX: First BCC
First Branchial Cleft
Presentation : Retroauricular, parotid, cervical (below mandible and above hyoid) Enlarging mass after infection with associated erythema and pain.
Cervical lesions may have a pit-like depression Tract can extend to EAC with drainage Evaluation : Imaging- MRI or CT Treatment : Surgical Excision
First Branchial Clefts
Second branchial cleft fistula Presentation: neck pit anterior to SCM that may drain Follows the embryologic course in between IC and EC, over CNs 12 and 9 and Into tonsillar fossa Can end blindly (sinus tract) Treatment is excision with one or two incisions +/- Tonsillectomy
Second Branchial Cleft Cyst Presentation : Cystic neck mass Evaluation : CT Treatment : Antibiotics and I&D if acutely infected. Excision when not infected
Third Branchial Cleft Cyst
CT Scan
Endoscopic view of left pyriform sinus
Left hemi-thyroidectomy and removal of tract
Preauricular Pit May have FH of pits Can be associated with Branchio-oto-renal syndrome If concerns for hearing loss or Renal problems, get audiogram and renal ultrasound.
Most present as isolated pits, without syndromic association.
Infected Preauricular Pit
STRIDOR
• Laryngomalacia is the most common cause of infantile stridor and represents over 75% of the cases. • inspiratory stridor caused by collapse of the epiglottis and arytenoid mucosa. • high-pitched musical or a low-pitched, course, fluttering stridor • stridor may initiated or exacerbated by agitation, feeding or while lying in the supine position. • Associated with GERD
Indications for stridor referral
• Respiratory distress • Failure to thrive • Dysphagia • Aspiration
Supraglottoplasty with Sinus Instruments
Microdebrider to remove extra arytenoid mucosa
Laryngeal cysts
• mucous retention cysts that present with stridor, respiratory distress, cyanosis, dysphagia, failure to thrive, or ALTE.
Vallecular cyst Treatment – marsupilization Symptoms resolve quickly after surgery Subglottic cyst From intubation trauma Can occur MONTHS after intubation Treatment- excision. High recurrence
Vocal Fold Paralysis
• 2 nd most common cause of stridor in neonates • CNS anomalies – Arnold-Chiari malformations, hydrocephalus, and myelomeningocele – pressure on the vagus nerve-> bilateral VFP • Congenital cardiovascular anomalies – pressure on the recurrent laryngeal nerve resulting in a unilateral vocal fold paralysis. • Trauma to the recurrent laryngeal nerve from a traumatic childbirth delivery or from surgery leads to vocal fold paralysis that may return with time.
Vocal fold paralysis
• Presentation – Stridor – Weak cry – Recurrent aspiration • Treatment – Time – Collagen injection – tracheostomy – Thyroplasty – Nerve reinnervation
Recurrent laryngeal nerve reinnervation
• For children with vocal fold paresis > 18 months – May be from PDA ligation or cardiac surgery • Dysphonia • Dysphagia/aspiration • Does not make the nerve move but gives bulk and tone which improves voice quality
Vocal Fold Granuloma
• Often have a history of recent intubation.
• May have stridor or hoarsness
Laryngeal Granuloma
Hoarseness
• Vocal Fold Nodules • Often from vocal abuse • Treatment: Speech therapy, antacids, rarely surgery
Hoarseness- Papillomas
HPV Maternal transmisison Can be seen with C sections
Cervical Lymphadenopathy
• Hundreds of lymph nodes in the head and neck • 38-45% of healthy children have palpable cervical lymph nodes • LAN defined as >1cm • The majority in children are benign, self-limited inflammatory processes
Concerned Parents
• Is this cancer?
• Many report family histories of cancer which heightens their concerns • Some have received reassurance from PMD but are still concerned.
• Some have sought multiple subspecialty consultations
Etiology of Cervical LAN
• Most common cause is reactive hyperplasia – From infectious process – Most commonly viral URI • Chronic posterior triangle lymphadenitis may the sole presentation of acquired toxoplasmosis • Malignant tumors – 25% of pediatric tumors occur in the head and neck – < 6yo, neuroblastoma and leukemia are the most common followed by rhabdomyosarcoma and non Hodgkin’s lymphoma – >6yo: Hodgkin’s lymphoma > non-Hodgkin’s lymphoma and rhabdomyosarcoma
• URI • EBV • CMV • Rubella • Rubeola • VZV • HSV • Coxsackievirus • HIV
Etiology- Viral
Etiology- Bacterial
• Staphylococcus aureus • Group A β-hemolytic streptococci • Anaerobes • Diphtheria • Cat-scratch disease • Tuberculosis • Protozoa - Toxoplasmosis
Malignancies
• Neuroblastoma • Leukemia • Lymphoma • Rhabdomyosarcoma
Influential Clinical Factors for LAN
• History of prior malignancy • Lymph node size, > 2-3 cm • Fluctuating size • Organomegaly (liver, spleen) are sometimes associated with malignancy • Duration of LAN is not correlated with serious pathology • Consistency of LN is not helpful but fixed lesions are likely to be malignant • Persistent fevers and weight loss may predict a serious pathology • Supraclavicular LNs should have a high index of suspicion. Up to 35% can be lymphoma
Laboratory Evaluation
• Not necessary in the majority of children but should be considered in some clinical situations • CBC – Leukocytosis and left shift- bacterial – Atypical lymphocytes- mono – Pancytopenia or blast cells- leukemia • Serologic titer tests – Bartonella – EBV- heterophile antibody test for mono has a high false negative rate in young children – CMV – Toxo • LDH- marker of cell turnover which can be high in malignancy • PPD
Ultrasound
• Many studies have attempted to correlate nodal architecture, hilar shape and vascularity with cancer predictions • Blurred nodal margins and formation of a nodal mass are found in both lymphoma and infection • Round shape is found in 9% of reactive LNs and 78% of lymphomas • Narrow or absent hilum is found in 6% of reactive LNs and 100% of lymphomas • Wide range of sensitivity and specificity. Therefore, further research is needed.
Reactive LN L/S >2 Ultrasound Lymphomatous LN L/S <2
FNA
• High specificity (92-100%) • Variable sensitivity- as low as 67% • Findings correlate with the skill and experience of the cytopathologist • FNA is very useful if there is a positive diagnosis • FNA can not adequately exclude serious pathology • Some kids require sedation
Jugulodigastric Lymph Nodes
• Commonly enlarged in children • >1.5 cm is considered lymphadenopathy • Enlarge from URIs and pharyngitis • Make sure it is not tonsillar hypertrophy you are palpating
Supraclavicular Lymph Nodes
• Always refer for biopsy no matter what the size is • High likelihood of being malignant with 1/3 being lymphoma
General Management Principles
• Most cases of LAN are self-limited • Failure to regress after 4-6 weeks (with antibiotics) may require diagnostic biopsy • Large persistent lymph nodes (>2cm) should be biopsied • ALL supraclavicular lymph nodes should be biopsied • FNA is only useful if the findings are positive • Excisional biopsy is the diagnostic gold standard
Rosai-Dorfman disease
• Sinus histiocytosis • Massive, painless cervical LAN • Usually presents in the first decade of life • Need a biopsy for confirmation • Most cases are self limiting
Kikuchi-Fujimoto disease
• Necrotizing lymphadenitis • Benign • More common in Japanese • F>M • Associated S&S: Fever, nausea, weight loss, night sweats, arthralgia, and hepatoplenomegaly • Diagnosis: Biopsy • Usually self limiting
Atypical mycobacterial lymphadenitis
• • Submandibular LNs most commonly involved
M avium-intracellulare scrofulaceum
and
M
• Discoloration of skin occasionally with sinus tract • CXR and PPD recommended • Treatment: Surgical excision, curettage +/- antibiotics • Some regress spontaneously
Post auricular dermoids and cysts
Postauricular Lymph Nodes
• Drainage basin from scalp, ear and temporoparietal areas.
• Examine for infections or breaks in the skin