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Pearls

  • 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

Pediatric Sinusitis

  • Major criteria for chronic pediatric sinusitis

    • Nasal obstruction

    • Purulent nasal discharge

  • Other presenting symptoms

    • Headache

    • Chronic cough

    • Behavioral change, irritability

    • Halitosis

    • Postnasal drainage

    • Daytime cough with exacerbation at night

  • Predisposing factors

    • Environmental

    • Allergy

    • Tobacco smoke

    • GERD

    • Immunodeficiency

    • Cystic fibrosis

      • Nasal polyps in a pediatric patient suggest CF until proven otherwise.

    • Ciliary dyskinesia

    • Infectious—viral, etc

  • Complications of pediatric rhinosinusitis

    • Meningitis

    • Epidural/subdural/intraparenchymal brain abscess

    • Orbital complications

      • Chandler classification

        • I: Periorbital cellulitis (pre-septal)

        • II: Orbital cellulitis

        • III: Sub-periosteal abscess

        • IV: Orbital abscess

        • V: Cavernous sinus thrombosis

      • 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

    • Indications for CT scanning for pediatric rhinosinusitis

      • Severe illness or toxic condition

      • Acute rhinosinusitis that does not improve with medical therapy in 48–72 h

      • Immunocompromised host

      • Presence of a suppurative complication other than orbital cellulitis

    • Bacteriology of acute pediatric sinusitis

      • Aerobes: Pneumococcus, Moraxella catarrhalis, Haemophilus influenzae, Staphylococcus aureus, α-hemolytic Strep, Pseudomonas

      • Anaerobes: Peptococcus, Peptostreptococcus, Bacteroides

    • Bacteriology of chronic pediatric sinusitis

      • Aerobes: S. aureus, Streptococcus pneumoniae, H. influenzae

      • Anaerobes: Prevotella, Porphyromonas, Fusobacterium

Velopharyngeal Insufficiency

  • Four patterns of velopharyngeal closure

    • Coronal (55 %, most common)

    • Sagittal (10–15 %, least common)

    • Circular (10–20 %)

    • Circular with Passavant’s ridge (15–20 %)

  • Management of velopharyngeal insufficiency (VPI)

    • Medical

      • Speech therapy

      • Prosthetics: palatal lift or obturator

      • Biofeedback with nasometry

    • Surgical

      • Pharyngoplasty

      • Use when good anterior–posterior motion, poor lateral motion

      • Pharyngeal flaps

      • Use when good lateral motion, poor anterior–posterior motion

      • Posterior pharyngeal wall augmentation

Upper Airway Infections

  • Laryngotracheitis (Croup)

    • Viral etiology (most commonly associated with parainfluenza)

    • Slow onset with URI prodrome leading to barky cough and inspiratory stridor

    • Presents in patients aged 6 months–3 years

    • AP neck X-ray with “steeple sign” (subglottic narrowing)

    • Supportive care with humidification, racemic epinephrine, ±steroids

    • Intubation rarely required and should be avoided if possible

  • Supraglottitis (epiglottitis)

    • Bacterial etiology (classically H. Influenza B)

    • Rapid onset with high fevers, dysphagia, drooling, and toxic appearance

    • Presents most commonly in patients aged 1–8 years

    • Lateral neck X-ray with “thumbprint sign” (swollen epiglottis)

    • Secure airway, IV antibiotics

      • OR intubation/bronchoscopy with tracheotomy equipment available; extubate once edema decreased and air leak present

  • Bacterial tracheitis

    • Bacterial etiology (S. Aureus, S. Pyogenes, H. Influenza, M. Catarrhalis)

    • May be bacterial superinfection after viral laryngotracheitis

    • URI prodrome with rapid escalation to toxic symptoms with high fevers, cough, hoarseness, and respiratory distress

    • IV antibiotics

    • OR intubation/bronchoscopy with therapeutic removal and culture of tracheal exudates

  • Retropharyngeal abscess

    • Mixed aerobic/anaerobic bacterial etiology

    • URI prodrome with slowly progressive sore throat, dysphagia, drooling, and decreased neck range of movement

    • Lateral neck X-ray (widening of pre-vertebral soft tissues) vs. CT scan

    • IV antibiotics—may obviate the need for surgical drainage

    • Secure airway as needed; possible OR drainage (trans-oral vs. trans-cervical)

Adenotonsillar Disease

  • Adenoid anatomy

    • Blood supply

      • Pharyngeal branch of the internal maxillary (major supply)

      • Ascending palatine branch of the facial artery

      • Ascending cervical branch of thyrocervical trunk

      • Ascending pharyngeal artery

    • Innervation: CNs IX and X

      • Histology: ciliated pseudostratified columnar, stratified squamous and transitional epithelia present; presence of inflammation increases specialized squamous epithelium proportion and decreases respiratory proportion

    • Indications for adenoidectomy

      • Infection

      • Recurrent/chronic adenoiditis

      • Chronic otitis media with or without effusion (kids >4 years)

      • Obstruction

        • Adenoid hyperplasia with chronic nasal obstruction or obligate mouth breathing

        • OSA or sleep disturbances

        • Associated with cor pulmonale, failure to thrive (FTT)

      • Craniofacial growth abnormalities

      • Occlusion abnormalities

      • Speech abnormalities

      • Swallowing abnormalities

      • Others

        • Suspected neoplasm

        • Chronic sinusitis

  • Tonsil anatomy

    • Blood supply to the tonsil

      • Facial artery (tonsillar branch, ascending palatine branch)

      • Dorsal lingual branch of lingual artery

      • Internal maxillary artery (descending palatine, greater palatine artery)

      • Ascending pharyngeal artery

    • Etiology of pseudomembranous tonsillitis

      • Epstein–Barr virus (mononucleosis)

      • Candidiasis

      • Vincent’s angina

      • Neisseria gonnorhoeae

      • Syphilis

      • Corynebacterium diphtheria

      • Group A β-hemolytic Streptococcus

    • Indications for tonsillectomy

      • Infection

        • Recurrent acute infections >7 in 1 year, >5/year in 2 years, >3/year in 3 or more years

        • Recurrent acute infections with complications (cardiac valve disease, febrile seizures)

        • Chronic tonsillitis associated with halitosis, persistent sore throat, tender cervical adenitis, unresponsive to medical therapy

        • Streptococcus carrier

        • Peritonsillar abscess

        • Tonsillitis with cervical abscess

        • Mononucleosis with obstructing tonsils unresponsive to therapy

        • PFAPA (see below: syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis)

        • Obstruction

        • Suspicion of malignancy

  • AAO-HNS guidelines for overnight admission post adenotonsillectomy

    • Severe OSA (AHI >10) or other craniofacial abnormalities

    • Emesis or hemorrhage

    • Age <3 years

    • Patient lives greater than 60 min away from hospital

    • Poor socioeconomic class which may predispose to neglect

    • Any other medical comorbidity which requires attention postoperatively (diabetes, seizures, Down syndrome, asthma, cardiac disease, etc.)

  • Complications of adenotonsillectomy

    • Postoperative hemorrhage: 0.5–10 %

    • 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

    • Hypoxemia: loss of hypercapneic respiratory drive

    • VPI

    • Nasopharyngeal stenosis

    • Atlantoaxial subluxation (Grisel’s syndrome): deep calcification of anterior arch of atlas, laxity of anterior transverse ligament; Down syndrome children more prone to this

      • Diagnosis: MRI or CT C-spine

      • Treatment: muscle relaxants, benzodiazepines, spine consultation/traction, cervical collar, NSAIDs

    • Malodorous breath (most common complaint)

  • PFAPA syndrome

    • Periodic high fevers, aphthous stomatitis, pharyngitis, cervical adenitis occurring every 3–5 weeks for at least 6 months

    • Repeated negative throat and viral cultures

    • Medical management with steroids, definitive surgical management with adenotonsillectomy

  • Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)

    • Not validated as a disease entity

      • Dx: GABHS-Ig

    • Rapid onset of obsessive compulsive disorder (OCD) in association with group A β-hemolytic streptococcal infections (GABHS)

    • Treatment: psychiatric medications for OCD, PCN/abx

Pediatric Head and Neck Masses

Most common neck mass in a child is inflammatory adenitis:

  • Treatment with antibiotics

  • Suppurative adenitis likely to require incision and drainage

  • Deep-space neck infection may present with neck mass/fullness

  • Cat scratch fever

    • Bartonella henselae

    • History of cat exposure

    • Dx: serum titer measurement

  • Atypical mycobacterial infection

    • Childhood disease, non-tender slowly enlarging neck mass, no pulmonary involvement or systemic, drug therapy usually ineffective (biaxin may be effective)

    • Tx: incision and drainage/curretage, may cause fistulization

Salivary Gland Masses

  • Most common pediatric salivary gland mass is hemangioma

  • Most common pediatric salivary gland neoplasm is pleomorphic adenoma

  • Most common pediatric salivary gland malignancy is mucoepidermoid carcinoma

  • Overall ~50 % of parotid gland neoplasms in children are malignant (vs. ~20 % in adults)

Small Blue-Cell Malignancies in Children

  • Lymphoma

  • Sarcoma

  • Rhabdomyosarcoma

    • Most common sites (descending order)

      • Orbit

      • Nasopharynx

      • Middle ear/mastoid

      • Sinonasal cavity

    • Metastatic sites

      • Lung

      • Bone

      • Bone marrow

    • Histopathology

      • Embryonal (75 %): most common in infants and children

        • Spindle-shaped cells with eosinophilic cytoplasm, best prognosis

        • Botryoid variant

      • Alveolar (20 %): most common in adolescents

        • Small round cells separated by fibrous septae into alveolar groups

      • Pleomorphic: most common in adults

  • PNET (neuroendocrine tumor)

Differential Diagnosis for Midline Neck Mass

  • Thyroglossal duct cyst

    • Embryologic remnant of tract from descent of thyroid gland from foramen cecum to natural anatomic position

    • Evaluate for the presence of normal thyroid gland using ultrasound prior to surgical management

    • Tx: Sistrunk procedure—excision of cyst, surrounding tissue, and central portion of hyoid; variable tract path

  • Teratoma

  • Dermoid

  • Lymphatic malformation

  • Plunging ranula

  • Thymic cyst

  • Hemangioma

Pediatric Base of Tongue Mass

  • Differential diagnosis

    • Lingual thyroid

    • Thyroglossal duct cyst

    • Vallecular cyst

  • Evaluation

    • Thyroid function tests: TSH, T3/T4

    • CT or MRI

    • I-131 scan: identify other foci of functioning thyroid tissue

  • Treatment of lingual thyroid: observation, thyroid suppression therapy, RAI, surgery

Lymphatic and Vascular Malformations

  • PHACE syndrome

  • Kasabach–Merritt syndrome

  • Sturge–Weber syndrome

  • Maffucci syndrome

  • von Hippel Lindau syndrome

    • Autosomal dominant

    • Hemangioblastomas of CNS and retinas, renal cysts/carcinoma, pheochromocytoma, pancreatic cysts, papillary cystadenomas of epididymis

    • Associated with endolymphatic sac tumors