NECK

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

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

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

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

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

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

LATERAL NECK

Lymphadenitis Bacterial infection of

the node Characteristics

Significant enlargement Tenderness Erythema Suppuration

Treatment Aggressive antibiotics Surgical intervention if

suppuration

LATERAL NECK

Chronic cervical lymphadenopathy >4 weeks DDx

Cat-scratch disease Atypical mycobacterial infection TB

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

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

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

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

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

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

CHEST WALL

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

CHEST WALL

Pectus carinatum “pigeon chest” Protrusion

deformity M>F Usually

asymptomatic Consider Marfan

Aortic root abnormalities

Lens subluxation

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

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

BREAST

Mastitis Common in infancy May progress to

abscess Treatment

Aggressive antibiotic therapy

Warm compresses Surgery – last resort

Permanent breast asymmetry and deformity

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

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

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

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.

ABDOMINAL WALL

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

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

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

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

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

INGUINAL DISORDERS

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

INGUINAL DISORDERS

Acute scrotal inflammation Incarcerated hernia Torsion of the

testicle Torsion of the

appendix testis Testicular trauma Epididymo-orchitis EMERGENCY

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

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

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

ANUS AND RECTUM

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

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

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

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

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