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When to refer to ENT: Lumps, bumps, and others.

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Presentation on theme: "When to refer to ENT: Lumps, bumps, and others."— Presentation transcript:

1 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

2 Epistaxis

3 Proper technique of stopping nose bleeds

4 Nasal blood vessel anatomy

5 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

6 Juvenile nasopharyngeal angiofibroma
In males Usually teenage Extensive bleeding May have nasal obstruction May have CN V sensory deficits

7 Congenital Nasal Masses- Dermoid

8 Midline nasal masses Dermoid Glioma Encephalocele
May extend intracranial Therefore, NEVER biopsy or cut open before obtaining a scan.

9 Parotitis

10 Congenital and Vascular Anomalies
Branchial cleft cyst Thyroglossal duct cyst Laryngocele Hemangioma AVM Lymphatic malformation

11 Hemangioma Beard distribution has high risk of subglottic hemangioma
High likelihood of having airway issues May need a trach

12 Congenital Anomalies Thyroglossal Duct Cyst

13 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%

14 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

15 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


17 First Branchial Clefts

18 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

19 Used 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.

20 Second Branchial Cleft Cyst
Presentation: Cystic neck mass Evaluation: CT Treatment: Antibiotics and I&D if acutely infected. Excision when not infected

21 Third Branchial Cleft Cyst

22 CT Scan

23 Endoscopic view of left pyriform sinus

24 Left hemi-thyroidectomy and removal of tract

25 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.

26 Infected Preauricular Pit

27 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

28 Indications for stridor referral
Respiratory distress Failure to thrive Dysphagia Aspiration

29 Supraglottoplasty with Sinus Instruments

30 Microdebrider to remove extra arytenoid mucosa

31 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


33 Vocal Fold Paralysis 2nd 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.

34 Vocal fold paralysis Presentation Stridor Weak cry
Recurrent aspiration Treatment Time Collagen injection tracheostomy Thyroplasty Nerve reinnervation

35 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

36 Vocal Fold Granuloma Often have a history of recent intubation.
May have stridor or hoarsness

37 Laryngeal Granuloma

38 Hoarseness Vocal Fold Nodules Often from vocal abuse
Treatment: Speech therapy, antacids, rarely surgery

39 Hoarseness- Papillomas
HPV Maternal transmisison Can be seen with C-sections

40 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

41 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

42 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

43 Etiology- Viral URI EBV CMV Rubella Rubeola VZV HSV Coxsackievirus HIV

44 Etiology- Bacterial Staphylococcus aureus
Group A β-hemolytic streptococci Anaerobes Diphtheria Cat-scratch disease Tuberculosis Protozoa- Toxoplasmosis

45 Malignancies Neuroblastoma Leukemia Lymphoma Rhabdomyosarcoma

46 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

47 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

48 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.

49 Ultrasound Lymphomatous LN L/S <2 Reactive LN L/S >2

50 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

51 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

52 Supraclavicular Lymph Nodes
Always refer for biopsy no matter what the size is High likelihood of being malignant with 1/3 being lymphoma

53 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

54 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

55 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

56 Atypical mycobacterial lymphadenitis
Submandibular LNs most commonly involved M avium-intracellulare and M scrofulaceum Discoloration of skin occasionally with sinus tract CXR and PPD recommended Treatment: Surgical excision, curettage +/- antibiotics Some regress spontaneously

57 Post auricular dermoids and cysts

58 Postauricular Lymph Nodes
Drainage basin from scalp, ear and temporoparietal areas. Examine for infections or breaks in the skin

59 QUESTIONS Call Center

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