thyroglossal duct cyst failure of regression of the thyroglossal duct prone to infection require...
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NECK
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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
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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
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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
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MIDLINE NECK
Other Midline branchial
(cervical) cleft Linear tract of
epithelialized tissue in the anterior midline of the neck
Due to aberrant fusion of the branchial arches
Thymic cyst Mediastinal lesions
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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 excisionD. Incision and drainageE. No treatment, this will resolve on its own
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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
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LATERAL NECK
Lymphadenitis Bacterial infection of
the node Characteristics
Significant enlargement Tenderness Erythema Suppuration
Treatment Aggressive antibiotics Surgical intervention if
suppuration
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LATERAL NECK
Chronic cervical lymphadenopathy >4 weeks DDx
Cat-scratch disease Atypical mycobacterial infection TB
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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
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LATERAL NECK
Mycobacterial infections Various clinical presentation
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
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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
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LATERAL NECK
Lymphoma Characteristics
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
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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
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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
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CHEST WALL
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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
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CHEST WALL
Pectus carinatum “pigeon chest” Protrusion
deformity M>F Usually
asymptomatic Consider Marfan
Aortic root abnormalities
Lens subluxation
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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
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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
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BREAST
Mastitis Common in infancy May progress to
abscess Treatment
Aggressive antibiotic therapy
Warm compresses Surgery – last resort
Permanent breast asymmetry and deformity
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BREAST
Masses Typically benign Preadolescent (6-7y)
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
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BREAST
Masses Fibrocystic disease
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
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BREAST Masses
Phyllodes tumors 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
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BREAST
Mass evaluation 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.
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ABDOMINAL WALL
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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
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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
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ABDOMINAL WALL
Management Goal
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
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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
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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
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INGUINAL DISORDERS
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INGUINAL DISORDERS
Hernias Presentation
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
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INGUINAL DISORDERS
Acute scrotal inflammation Incarcerated hernia Torsion of the
testicle Torsion of the
appendix testis Testicular trauma Epididymo-orchitis EMERGENCY
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INGUINAL DISORDERS
Testicular torsion Acutely tender testicle Retracted toward
inguinal region Transverse lie Immediate surgery
Torsion of appendix testis Blue dot sign Does not require
surgery
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QUESTION 10
At what age should this patient be referred to surgery if the condition has not resolved?
A. 1-3 monthsB. 3-6 monthsC. 6-9 monthsD. 12-18 monthsE. 2 years
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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
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ANUS AND RECTUM
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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
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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
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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
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ANUS AND RECTUM
Rectal prolapse Nonidiopathic
Spina bifida Other spinal cord abnormalities Chronic hookworm infestation Rectal polyps CF
Management Circumferential submucosal injections with
concentrated dextrose Sclerosant
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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