Abstract
Croup-like symptoms on presentation for the child <6 months of age should be of concern for possible subglottic hemangioma. After maximization of medical therapy, adenoidectomy is the first-line surgical option for recurrent, acute sinusitis/adenoiditis in children. Consider adenoidectomy to help treat underlying Eustachian tube dysfunction. Nasal polyposis in a child should prompt a work-up for cystic fibrosis. Torticollis or decreased neck range of motion post-tonsillectomy should be suspicious for Grisel’s syndrome. Neck masses in children are most commonly the result of an infectious process.
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Keywords
- Down Syndrome
- Obsessive Compulsive Disorder
- Pleomorphic Adenoma
- Thyroglossal Duct Cyst
- Aphthous Stomatitis
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Pearls
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Croup-like symptoms on presentation for the child <6 months of age should be of concern for possible subglottic hemangioma
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After maximization of medical therapy, adenoidectomy is the first-line surgical option for recurrent, acute sinusitis/adenoiditis in children
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Consider adenoidectomy to help treat underlying Eustachian tube dysfunction
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Nasal polyposis in a child should prompt a work-up for cystic fibrosis
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Torticollis or decreased neck range of motion post-tonsillectomy should be suspicious for Grisel’s syndrome
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Neck masses in children are most commonly the result of an infectious process
Pediatric Sinusitis
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Major criteria for chronic pediatric sinusitis
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Nasal obstruction
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Purulent nasal discharge
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Other presenting symptoms
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Headache
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Chronic cough
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Behavioral change, irritability
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Halitosis
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Postnasal drainage
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Daytime cough with exacerbation at night
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Predisposing factors
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Environmental
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Allergy
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Tobacco smoke
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GERD
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Immunodeficiency
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Cystic fibrosis
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Nasal polyps in a pediatric patient suggest CF until proven otherwise.
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Ciliary dyskinesia
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Infectious—viral, etc
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Complications of pediatric rhinosinusitis
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Meningitis
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Epidural/subdural/intraparenchymal brain abscess
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Orbital complications
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Chandler classification
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I: Periorbital cellulitis (pre-septal)
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II: Orbital cellulitis
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III: Sub-periosteal abscess
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IV: Orbital abscess
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V: Cavernous sinus thrombosis
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Stage I and II can generally be managed with intravenous antibiotics. Stage IV and V require urgent surgical intervention. Small medial sub-periosteal abscesses may be treated with a trial of intravenous antibiotics with close observation and a low threshold for surgical intervention if clinical improvement is not seen
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Indications for CT scanning for pediatric rhinosinusitis
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Severe illness or toxic condition
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Acute rhinosinusitis that does not improve with medical therapy in 48–72 h
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Immunocompromised host
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Presence of a suppurative complication other than orbital cellulitis
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Bacteriology of acute pediatric sinusitis
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Aerobes: Pneumococcus, Moraxella catarrhalis, Haemophilus influenzae, Staphylococcus aureus, α-hemolytic Strep, Pseudomonas
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Anaerobes: Peptococcus, Peptostreptococcus, Bacteroides
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Bacteriology of chronic pediatric sinusitis
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Aerobes: S. aureus, Streptococcus pneumoniae, H. influenzae
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Anaerobes: Prevotella, Porphyromonas, Fusobacterium
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Velopharyngeal Insufficiency
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Four patterns of velopharyngeal closure
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Coronal (55 %, most common)
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Sagittal (10–15 %, least common)
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Circular (10–20 %)
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Circular with Passavant’s ridge (15–20 %)
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Management of velopharyngeal insufficiency (VPI)
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Medical
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Speech therapy
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Prosthetics: palatal lift or obturator
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Biofeedback with nasometry
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Surgical
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Pharyngoplasty
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Use when good anterior–posterior motion, poor lateral motion
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Pharyngeal flaps
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Use when good lateral motion, poor anterior–posterior motion
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Posterior pharyngeal wall augmentation
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Upper Airway Infections
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Laryngotracheitis (Croup)
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Viral etiology (most commonly associated with parainfluenza)
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Slow onset with URI prodrome leading to barky cough and inspiratory stridor
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Presents in patients aged 6 months–3 years
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AP neck X-ray with “steeple sign” (subglottic narrowing)
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Supportive care with humidification, racemic epinephrine, ±steroids
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Intubation rarely required and should be avoided if possible
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Supraglottitis (epiglottitis)
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Bacterial etiology (classically H. Influenza B)
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Rapid onset with high fevers, dysphagia, drooling, and toxic appearance
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Presents most commonly in patients aged 1–8 years
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Lateral neck X-ray with “thumbprint sign” (swollen epiglottis)
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Secure airway, IV antibiotics
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OR intubation/bronchoscopy with tracheotomy equipment available; extubate once edema decreased and air leak present
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Bacterial tracheitis
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Bacterial etiology (S. Aureus, S. Pyogenes, H. Influenza, M. Catarrhalis)
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May be bacterial superinfection after viral laryngotracheitis
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URI prodrome with rapid escalation to toxic symptoms with high fevers, cough, hoarseness, and respiratory distress
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IV antibiotics
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OR intubation/bronchoscopy with therapeutic removal and culture of tracheal exudates
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Retropharyngeal abscess
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Mixed aerobic/anaerobic bacterial etiology
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URI prodrome with slowly progressive sore throat, dysphagia, drooling, and decreased neck range of movement
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Lateral neck X-ray (widening of pre-vertebral soft tissues) vs. CT scan
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IV antibiotics—may obviate the need for surgical drainage
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Secure airway as needed; possible OR drainage (trans-oral vs. trans-cervical)
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Adenotonsillar Disease
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Adenoid anatomy
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Blood supply
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Pharyngeal branch of the internal maxillary (major supply)
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Ascending palatine branch of the facial artery
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Ascending cervical branch of thyrocervical trunk
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Ascending pharyngeal artery
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Innervation: CNs IX and X
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Histology: ciliated pseudostratified columnar, stratified squamous and transitional epithelia present; presence of inflammation increases specialized squamous epithelium proportion and decreases respiratory proportion
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Indications for adenoidectomy
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Infection
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Recurrent/chronic adenoiditis
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Chronic otitis media with or without effusion (kids >4 years)
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Obstruction
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Adenoid hyperplasia with chronic nasal obstruction or obligate mouth breathing
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OSA or sleep disturbances
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Associated with cor pulmonale, failure to thrive (FTT)
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Craniofacial growth abnormalities
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Occlusion abnormalities
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Speech abnormalities
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Swallowing abnormalities
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Others
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Suspected neoplasm
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Chronic sinusitis
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Tonsil anatomy
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Blood supply to the tonsil
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Facial artery (tonsillar branch, ascending palatine branch)
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Dorsal lingual branch of lingual artery
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Internal maxillary artery (descending palatine, greater palatine artery)
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Ascending pharyngeal artery
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Etiology of pseudomembranous tonsillitis
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Epstein–Barr virus (mononucleosis)
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Candidiasis
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Vincent’s angina
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Neisseria gonnorhoeae
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Syphilis
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Corynebacterium diphtheria
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Group A β-hemolytic Streptococcus
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Indications for tonsillectomy
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Infection
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Recurrent acute infections >7 in 1 year, >5/year in 2 years, >3/year in 3 or more years
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Recurrent acute infections with complications (cardiac valve disease, febrile seizures)
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Chronic tonsillitis associated with halitosis, persistent sore throat, tender cervical adenitis, unresponsive to medical therapy
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Streptococcus carrier
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Peritonsillar abscess
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Tonsillitis with cervical abscess
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Mononucleosis with obstructing tonsils unresponsive to therapy
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PFAPA (see below: syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
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Obstruction
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Suspicion of malignancy
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AAO-HNS guidelines for overnight admission post adenotonsillectomy
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Severe OSA (AHI >10) or other craniofacial abnormalities
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Emesis or hemorrhage
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Age <3 years
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Patient lives greater than 60 min away from hospital
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Poor socioeconomic class which may predispose to neglect
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Any other medical comorbidity which requires attention postoperatively (diabetes, seizures, Down syndrome, asthma, cardiac disease, etc.)
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Complications of adenotonsillectomy
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Postoperative hemorrhage: 0.5–10 %
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Postoperative pulmonary edema: due to loss of auto-PEEP from chronic obstruction and decreased intrathoracic pressure. Treat with diuretics, fluid restriction, CPAP. Intubation if necessary to control O2 saturation
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Hypoxemia: loss of hypercapneic respiratory drive
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VPI
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Nasopharyngeal stenosis
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Atlantoaxial subluxation (Grisel’s syndrome): deep calcification of anterior arch of atlas, laxity of anterior transverse ligament; Down syndrome children more prone to this
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Diagnosis: MRI or CT C-spine
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Treatment: muscle relaxants, benzodiazepines, spine consultation/traction, cervical collar, NSAIDs
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Malodorous breath (most common complaint)
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PFAPA syndrome
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Periodic high fevers, aphthous stomatitis, pharyngitis, cervical adenitis occurring every 3–5 weeks for at least 6 months
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Repeated negative throat and viral cultures
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Medical management with steroids, definitive surgical management with adenotonsillectomy
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Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)
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Not validated as a disease entity
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Dx: GABHS-Ig
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Rapid onset of obsessive compulsive disorder (OCD) in association with group A β-hemolytic streptococcal infections (GABHS)
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Treatment: psychiatric medications for OCD, PCN/abx
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Pediatric Head and Neck Masses
Most common neck mass in a child is inflammatory adenitis:
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Treatment with antibiotics
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Suppurative adenitis likely to require incision and drainage
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Deep-space neck infection may present with neck mass/fullness
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Cat scratch fever
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Bartonella henselae
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History of cat exposure
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Dx: serum titer measurement
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Atypical mycobacterial infection
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Childhood disease, non-tender slowly enlarging neck mass, no pulmonary involvement or systemic, drug therapy usually ineffective (biaxin may be effective)
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Tx: incision and drainage/curretage, may cause fistulization
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Salivary Gland Masses
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Most common pediatric salivary gland mass is hemangioma
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Most common pediatric salivary gland neoplasm is pleomorphic adenoma
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Most common pediatric salivary gland malignancy is mucoepidermoid carcinoma
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Overall ~50 % of parotid gland neoplasms in children are malignant (vs. ~20 % in adults)
Small Blue-Cell Malignancies in Children
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Lymphoma
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Sarcoma
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Rhabdomyosarcoma
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Most common sites (descending order)
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Orbit
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Nasopharynx
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Middle ear/mastoid
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Sinonasal cavity
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Metastatic sites
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Lung
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Bone
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Bone marrow
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Histopathology
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Embryonal (75 %): most common in infants and children
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Spindle-shaped cells with eosinophilic cytoplasm, best prognosis
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Botryoid variant
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Alveolar (20 %): most common in adolescents
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Small round cells separated by fibrous septae into alveolar groups
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Pleomorphic: most common in adults
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PNET (neuroendocrine tumor)
Differential Diagnosis for Midline Neck Mass
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Thyroglossal duct cyst
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Embryologic remnant of tract from descent of thyroid gland from foramen cecum to natural anatomic position
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Evaluate for the presence of normal thyroid gland using ultrasound prior to surgical management
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Tx: Sistrunk procedure—excision of cyst, surrounding tissue, and central portion of hyoid; variable tract path
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Teratoma
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Dermoid
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Lymphatic malformation
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Plunging ranula
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Thymic cyst
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Hemangioma
Pediatric Base of Tongue Mass
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Differential diagnosis
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Lingual thyroid
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Thyroglossal duct cyst
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Vallecular cyst
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Evaluation
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Thyroid function tests: TSH, T3/T4
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CT or MRI
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I-131 scan: identify other foci of functioning thyroid tissue
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Treatment of lingual thyroid: observation, thyroid suppression therapy, RAI, surgery
Lymphatic and Vascular Malformations
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PHACE syndrome
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Kasabach–Merritt syndrome
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Sturge–Weber syndrome
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Maffucci syndrome
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von Hippel Lindau syndrome
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Autosomal dominant
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Hemangioblastomas of CNS and retinas, renal cysts/carcinoma, pheochromocytoma, pancreatic cysts, papillary cystadenomas of epididymis
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Associated with endolymphatic sac tumors
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Fuchsmann C, Quintal MC, Giguere C, et al. Propranolol as first-line treatment of head and neck hemangiomas. Arch Otolaryngol Head Neck Surg. 2011;137(5):471–8.
Grisaru-Soen G, Komisar O, Aizenstein O, et al. Retropharyngeal and parapharyngeal abscess in children—epidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol. 2010;74(9):1016–20.
Peridis S, Pilgrim G, Koudoumnakis E, et al. PFAPA syndrome in children: a meta-analysis on surgical versus medical treatment. Int J Pediatr Otorhinolaryngol. 2010;74(11):1203–8.
Shulman ST. Pediatric autoimmune neuropsychiatric disorders associated with streptococci (PANDAS): update. Curr Opin Pediatr. 2009;21(1):127–30.
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Cheng, J., Berg, E. (2014). General Pediatric Otolaryngology. In: Lin, F., Patel, Z. (eds) ENT Board Prep. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8354-0_2
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