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Neck.

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Presentation on theme: "Neck."— Presentation transcript:

1 Neck

2 Midline Neck Thyroglossal duct cyst
Failure of regression of the thyroglossal duct Prone to infection Require surgical excision Resection of midportion of hyoid and ligation of tract

3 Midline Neck Thyroid nodules Common
Greater incidence of malignancy in children Twice as common in girls Presentation Midline cervical mass Moves with thyroid PE Location Associated lymphadenopathy

4 Midline Neck Thyroid nodules Clinical findings unreliable
Imaging is rarely helpful Multiple nodules suggestive of Hashimoto FNA Debated in pediatric population Helpful if lesion benign Surgical excision Malignancy Indeterminant Benign lesions that cancer cannot be ruled out

5 Midline Neck Other Midline branchial (cervical) cleft Thymic cyst
Linear tract of epithelialized tissue in the anterior midline of the neck Due to aberrant fusion of the branchial arches Thymic cyst Mediastinal lesions

6 Question 9 A 3yo M returns to your clinic with a 4 ½ week history of a lateral neck mass. The mass is 4cm and firm. The Bartonella titers you ordered last week are negative. The child is otherwise healthy besides a recent URI and you suspect a mycobacterial infection. What is the treatment? A. Short course of antibiotics (1 week) B. Long course of antibiotics (4 weeks) C. Surgical excision D. Incision and drainage E. No treatment, this will resolve on its own

7 Lateral Neck Most common Benign reactive cervical lymphadenopathy
Nonspecific hyperplastic responses URI or face/scalp infections Characteristics <2cm Rubbery Oval Isolated 2-10 y Streptococcus pyogenes and Staphylococcus aureus Spontaneous regression following resolution of infection

8 Lateral Neck Lymphadenitis Bacterial infection of the node
Characteristics Significant enlargement Tenderness Erythema Suppuration Treatment Aggressive antibiotics Surgical intervention if suppuration

9 Lateral Neck Chronic cervical lymphadenopathy >4 weeks DDx
Cat-scratch disease Atypical mycobacterial infection TB

10 Lateral Neck Cat-scratch disease Common
Regional nodal enlargement 2-4 weeks following inoculation by dog or cat Lymphadenopathy persists for several months May require surgical drainage if suppurative Diagnosis Serologic testing PCR of nodal tissue Warthin-Starry stain on tissue specimen Bartonella

11 Lateral Neck Mycobacterial infections Various clinical presentation TB
Local adenopathy Pulmonary infection Disseminated disease TB Rare cervical or supraclavicular lymphadenopathy Manifestation of significant intrathoracic disease Treatment Aggressive antimycobacterial therapy Avoid surgery Chronic draining sinus

12 Lateral Neck MAIC complex Most common
Submandibular, submaxillary or preauricular lymph nodes Characteristics Large Firm Immobile Nontender May undergo spontaneous breakdown with abscess and sinus formation Treatment Complete resection

13 Lateral Neck Lymphoma Characteristics More common in Hodgkin
Painless cervical adenopathy Absence of antecedent URI or cutaneous infection Persistence of nodes beyond 6 weeks Size >2cm Firm More common in Hodgkin Incisional biopsy Other malignancies – non-Hodgkin, neuroblastoma, rhabdomyosarcoma, secondary metastases

14 Lateral Neck Branchial cleft anomalies Second branchial cleft
Most common Opening along the lower anterior border of SCM Complete fistula Drainage Incomplete fistula Cystic structure Secondary infection is common Treatment Excision

15 Lateral Neck Fibromatosis coli Fibrous dysplasia of the SCM
Mass in the lower neck Tilting of the head and face to the side of the lesion Older children may have hemifacial hypoplasia and asymmetry Treatment PT early Prevents plagiocephaly and facial asymmetry Surgery late

16 Chest wall

17 Chest Wall Pectus excavatum “funnel chest”
Most common congenital chest wall deformity Posterior angulation of the sternum toward the spine 3M:1F Deformity increases during childhood and adolescence Treatment Surgical repair If symptomatic Exercise intolerance, MVP, GER If self-esteem problems

18 Chest Wall Pectus carinatum “pigeon chest” Protrusion deformity M>F
Usually asymptomatic Consider Marfan Aortic root abnormalities Lens subluxation

19 Chest Wall Pectus carinatum Poland syndrome
Unilateral agenesis or dysplasia of the rib cage and chondral cartilages Absence of pectoralis major and minor Hand deformities Breast and areolar defects

20 Axilla Most often lymphatic Benign reactive lymphadenopathy
Most common mass Cystic hygromas or lymphangiomas May extend into mediastinum Hiradenitis Obstruction of sebaceous and sweat gland Mass that may become superinfected and require surgical drainage

21 Breast Mastitis Common in infancy May progress to abscess Treatment
Aggressive antibiotic therapy Warm compresses Surgery – last resort Permanent breast asymmetry and deformity

22 Breast Masses Typically benign Preadolescent (6-7y) Adolescents
Firm mobile mass under one or both areolae Precocious thelarche Never biopsy Adolescents Fibroadenomas 90% Smooth and mobile 1-2cm Juvenile variant Larger lesions with significant asymmetry Low malignant potential Treatment Excision Do not spontaneously resolve

23 Breast Masses Fibrocystic disease Pubertal gynecomastia in males
Older teens and young women One or multiple firm, fixed and ill-defined msses Hyperplasia of the fibrous parenchymal tissue Variations throughout menstral cycle Benign Pubertal gynecomastia in males Benign overgrowth of glandular tissue Early puberty Surgical intervention if psychosocial problems

24 Breast Masses Nipple discharge Phyllodes tumors Purulence
Rare fibroepithelial tumors Benign with aggressive local behavior May lead to malignancy and distant metastases Surgical evaluation early Nipple discharge Purulence Infection Green or brown Cyst Bloody Intraductal papilloma in children Cancer in adults Galactorrhea Endogenous hormones from tumor or pregnancy

25 Breast Mass evaluation Most masses can be serially monitored
History and Family History Mammography Limited due to dense tissue US Good for cystic lesions Needle aspiration MRI Chest wall involvement Most masses can be serially monitored Excisional biopsy may be indicated for a small group of postpubertal girls with lesions increasing in size.

26 Abdominal Wall

27 Abdominal Wall Omphalocele
Embryonic extrusion of the developing midgut while abdominal wall expands Defect in the abdominal wall Covered by a sac Outer amniotic Inner peritoneal Umbilical cord insertion Wide range of sizes Coexisting anomalies 30-50% Heart Sternum Diaphragm Bladder Chromosomal

28 Abdominal Wall Gastroschisis
Defect of the right lateral abdominal wall May be due to vascular accident leading to disruption of abdominal wall Defect is usually small May have large amount of bowel extruded Bowel in contact with amniotic fluid Intense inflammatory response or “peel” Peel may alter bowel motility post op 7-10% associated conditions Intestinal atresias Volvulus, malrotation or incarceration

29 Abdominal Wall Management Goal Complications Timing
Safe primary closure Staged closure Prosthetic Silastic silo with daily reductions Prosthetic material Complications Abdominal compartment syndrome Pulmonary embarrassment Renal insufficiency Intestinal ischemia or NEC Timing Gastroschisis – emergent Omphalocele – more elective

30 Umbilicus Umbilical hernia Most common condition of the abdominal wall
Failed closure of the fascial ring Usually closes in 2-3 years Strong familial and racial predilection AA Treatment Repair Delay until age 5 >2cm “elephant’s trunk” Incarceration

31 Umbilicus Granulomas Polypoid mucosal-appearing lesion at the base of umbilicus Residual tissue at the base of the cord Treatment Topical Alcohol Silver nitrate sticks

32 Inguinal Disorders Problems with the processus vaginalis – out pouching of the peritoneal cavity taken down with the descent of the testicles. The processus vaginalis should obliterate at the end of descent. fusion of the processus vaginalis occurs earlier in development for girls explaining the low incidence. Ovaries are typically found in hernia sacs

33 Inguinal Disorders Hernias Presentation Complications Treatment
Bulges in the groin and scrotum or labial majora Increase with valsalva Reduces spontaneously or with pressure Complications Incarceration Unable to reduce 30% Treatment Prompt repair No spontaneous resolution

34 Inguinal Disorders Acute scrotal inflammation Incarcerated hernia
Torsion of the testicle Torsion of the appendix testis Testicular trauma Epididymo-orchitis EMERGENCY

35 Inguinal Disorders Testicular torsion Torsion of appendix testis
Acutely tender testicle Retracted toward inguinal region Transverse lie Immediate surgery Torsion of appendix testis Blue dot sign Does not require surgery Epididymis is on the left

36 Question 10 At what age should this patient be referred to surgery if the condition has not resolved? A. 1-3 months B. 3-6 months C. 6-9 months D months E. 2 years Answer D

37 Inguinal Disorders Hydroceles Common in infancy
Diminish during childhood Characteristics Scrotal swellings Diurnal variation Transillumination Birth Noncommunicating Resolve by 1 year Surgery Communicating Persistent >12-18 months of age Persistent after infection or trauma

38 Anus and Rectum

39 Anus and Rectum Imperforate anus Low
Passage of the rectum through the levator ani Fistulous tract to perineal region ending Center of a ridge of tissue Bucket handle deformity Anterior to the structures as a perineal fistula Favorable prognosis Passes through levator ani

40 Anus and Rectum Imperfortate anus High No visual fistula
No levator ani Fistula to Prostatic urethra Bulbar urethra Bladder neck Hymen Meconium passed with urine or transvaginally Management Perineal anoplasty One or multiple stages involving colostomy May change in future Prognosis guarded due to other anomalies

41 Anus and Rectum Rectal prolapse Uncommon Most often idiopathic
Peak at 2y Precipitated by Diarrheal illness Toilet training Severe constipation Management Resolves spontaneously Dietary or medical manipulations for constipation

42 Anus and Rectum Rectal prolapse Nonidiopathic Management Spina bifida
Other spinal cord abnormalities Chronic hookworm infestation Rectal polyps CF Management Circumferential submucosal injections with concentrated dextrose Sclerosant

43 Anus and Rectum Anorectal abscess Common 6-10 months
Infection of submucosal crypt glands Complications Recurrent episodes lead to fistulas or chronically draining sinuses Crohn, CGD, Immunodeficiency Management I & D if fluctuant Warm soaks Sitz baths Anal fistulectomy


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