Presentation on theme: "When to refer to ENT: Lumps, bumps, and others."— Presentation transcript:
1When to refer to ENT: Lumps, bumps, and others. David J. Brown, M.D.Associate ProfessorDivision of Pediatric OtolaryngologyInterim Associate Vice President and Associate Dean for Health Equity and Inclusion
5Nose bleed maintenance Keep moistHumidifierNasal salineOintment along septumKeep fingers out of noseTrim fingernailsCan refer if these measures don’t work, significant bleeding, and/or parents want to consider nasal cautery
6Juvenile nasopharyngeal angiofibroma In malesUsually teenageExtensive bleedingMay have nasal obstructionMay have CN V sensory deficits
13Branchial Cleft Anomalies Second most common head and neck congenital lesion20% of congenital cervical masses in children1% are bilateralThought to occur secondary to incomplete obliteration of the branchial clefts and pouches during embryogenesisSecond: 40-95%First: 5-25%Third/Fourth: 2-8%
14Case4 yo girl presents with postauricular mass.Had been infected twice and I&D performed at OSH EDPE: Post-auricular non-tender cystic mass.DX: First BCC
15First 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 depressionTract can extend to EAC with drainageEvaluation:Imaging- MRI or CTTreatment:Surgical Excision
18Second branchial cleft fistula Presentation: neck pit anterior to SCM that may drainFollows the embryologic course in between IC and EC, over CNs 12 and 9 andInto tonsillar fossaCan end blindly (sinus tract)Treatment is excision with one or two incisions+/- Tonsillectomy
19Used to use methylene blue (0 Used to use methylene blue (0.5cc) but stopped because of reported adverse reactions. Now use injectable saline with food coloring. Patient is intubated and has mouth gag for Tonsillectomy. Use the smallest angiocath and place in the direction of the tract. Should flow freely. If there is a fisula, you will see the color in the pharynx. Do Tonsillectomy and can find the exact location. Can be ANYWHERE is tonils. If possible I try to free the tract from the tonsillar fossa with the bovie. Do the neck portion and pull through. Here you can see the charred end from the bovie. Technique not always possible- depends on location.
20Second Branchial Cleft Cyst Presentation: Cystic neck massEvaluation: CTTreatment: Antibiotics and I&D if acutely infected. Excision when not infected
25Preauricular Pit May have FH of pits Can be associated with Branchio-oto-renal syndromeIf concerns for hearing loss orRenal problems, get audiogram and renal ultrasound.Most present as isolated pits, without syndromic association.
27STRIDORLaryngomalacia 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 stridorstridor may initiated or exacerbated by agitation, feeding or while lying in the supine position.Associated with GERD
28Indications for stridor referral Respiratory distressFailure to thriveDysphagiaAspiration
33Vocal Fold Paralysis 2nd most common cause of stridor in neonates CNS anomaliesArnold-Chiari malformations, hydrocephalus, and myelomeningocelepressure on the vagus nerve-> bilateral VFPCongenital cardiovascular anomaliespressure 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.
35Recurrent laryngeal nerve reinnervation For children with vocal fold paresis > 18 monthsMay be from PDA ligation or cardiac surgeryDysphoniaDysphagia/aspirationDoes not make the nerve move but gives bulk and tone which improves voice quality
36Vocal Fold Granuloma Often have a history of recent intubation. May have stridor or hoarsness
38Hoarseness Vocal Fold Nodules Often from vocal abuse Treatment: Speech therapy, antacids, rarely surgery
39Hoarseness- Papillomas HPVMaternal transmisisonCan be seen with C-sections
40Cervical Lymphadenopathy Hundreds of lymph nodes in the head and neck38-45% of healthy children have palpable cervical lymph nodesLAN defined as >1cmThe majority in children are benign, self-limited inflammatory processes
41Concerned Parents Is this cancer? Many report family histories of cancer which heightens their concernsSome have received reassurance from PMD but are still concerned.Some have sought multiple subspecialty consultations
42Etiology of Cervical LAN Most common cause is reactive hyperplasiaFrom infectious processMost commonly viral URIChronic posterior triangle lymphadenitis may the sole presentation of acquired toxoplasmosisMalignant tumors25% 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
46Influential Clinical Factors for LAN History of prior malignancyLymph node size, > 2-3 cmFluctuating sizeOrganomegaly (liver, spleen) are sometimes associated with malignancyDuration of LAN is not correlated with serious pathologyConsistency of LN is not helpful but fixed lesions are likely to be malignantPersistent fevers and weight loss may predict a serious pathologySupraclavicular LNs should have a high index of suspicion. Up to 35% can be lymphoma
47Laboratory Evaluation Not necessary in the majority of children but should be considered in some clinical situationsCBCLeukocytosis and left shift- bacterialAtypical lymphocytes- monoPancytopenia or blast cells- leukemiaSerologic titer testsBartonellaEBV- heterophile antibody test for mono has a high false negative rate in young childrenCMVToxoLDH- marker of cell turnover which can be high in malignancyPPD
48UltrasoundMany studies have attempted to correlate nodal architecture, hilar shape and vascularity with cancer predictionsBlurred nodal margins and formation of a nodal mass are found in both lymphoma and infectionRound shape is found in 9% of reactive LNs and 78% of lymphomasNarrow or absent hilum is found in 6% of reactive LNs and 100% of lymphomasWide range of sensitivity and specificity. Therefore, further research is needed.
50FNA High specificity (92-100%) Variable sensitivity- as low as 67% Findings correlate with the skill and experience of the cytopathologistFNA is very useful if there is a positive diagnosisFNA can not adequately exclude serious pathologySome kids require sedation
51Jugulodigastric Lymph Nodes Commonly enlarged in children>1.5 cm is considered lymphadenopathyEnlarge from URIs and pharyngitisMake sure it is not tonsillar hypertrophy you are palpating
52Supraclavicular Lymph Nodes Always refer for biopsy no matter what the size isHigh likelihood of being malignant with 1/3 being lymphoma
53General Management Principles Most cases of LAN are self-limitedFailure to regress after 4-6 weeks (with antibiotics) may require diagnostic biopsyLarge persistent lymph nodes (>2cm) should be biopsiedALL supraclavicular lymph nodes should be biopsiedFNA is only useful if the findings are positiveExcisional biopsy is the diagnostic gold standard
54Rosai-Dorfman disease Sinus histiocytosisMassive, painless cervical LANUsually presents in the first decade of lifeNeed a biopsy for confirmationMost cases are self limiting
55Kikuchi-Fujimoto disease Necrotizing lymphadenitisBenignMore common in JapaneseF>MAssociated S&S: Fever, nausea, weight loss, night sweats, arthralgia, and hepatoplenomegalyDiagnosis: BiopsyUsually self limiting
56Atypical mycobacterial lymphadenitis Submandibular LNs most commonly involvedM avium-intracellulare and M scrofulaceumDiscoloration of skin occasionally with sinus tractCXR and PPD recommendedTreatment: Surgical excision, curettage +/- antibioticsSome regress spontaneously