Post on 22-Jan-2016
Clinical Pearls
Eric D. Baum, MDConnecticut Pediatric Otolaryngology
Madison · North Haven · Shelton · Yale-New Haven Children’s Hospital
Nasal Dermoid Sinus Cyst
• Most common congenital midline nasal lesion– Also consider glioma or encephalocele
• Look for other anomalies– Other midline defects– Other head and neck defects
• Must be evaluated for intracranial extension
Quach KA, Horner KL, et al. Arch Pediatr Adolesc Med, 2010.
Diagnosis
• Midline cyst or mass anywhere from glabella to root of columella
• Often will have a pit – which might drain sebaceous stuff– if there’s hair in the pit, pathognomonic
Re M, Tarchini P et al. Int J Ped ORL, 2012.
Embryology and Workup
Cambiaghi S, Micheli S, et al. Ped Dermatol, 2007.
Must Completely Excise• Many surgical approaches
– Direct excision with vertical incision– Open rhinoplasty
• Intracranial excision may be required– Classic: bicoronal craniotomy– Many smaller craniotomies possible
Locke R, Kubba H, Int J Ped ORL, 2011.Goyal P, GellmanRM, Arch Facial Plastic Surg, 2007.
Timing of Nasal Fracture Evaluation
• Too soon: edema often obscures examination
• Too late: closed reduction no longer possible
• There is no data
Pediatric Nasal Fracture
• Young children less likely to fracture– Not impossible– May be easier to dislocate
septum• Adolescents mostly like
adults– Distal (inferior) portion of
nasal bones– Further injury always
possible
Initial Evaluation
• Usual overall assessment–Other injuries–Intracranial
• Physical exam–Describe nasal abnormality–Radiologic studies rarely helpful–Must rule out septal hematoma
Septal Hematoma - Urgent
AO Foundation Website, 2012
Septal Hematoma - Exam
www.entusa.com, 2012Soma DB, Homme JH. Int J Ped ORL, 2011.
Secondary Evaluation
• This is where timing is tricky– Best to call
• Photographs can be helpful– Pre-injury– Immediate (or at least
within a few hours)• Most isolated nasal fractures
amenable to closed reduction– Within 1-2 weeks– Not 100% success rate
Love RL. N Z Med J, 2010.
Auricular Hematoma
• Same idea as septal hematoma• Shear forces on lateral auricle• Teenage boys
– Wrestling– Boxing– Martial arts
Presentation & Evaluation
• Rule out other injuries– Pressure injury from side can rupture eardrum
• History is important– “Classic” sports very common– Plenty of repeat business– If not athletic, why?
• Specific timing important– Within a few hours, fluid may thicken and organize– Very early injuries: needle aspiration only– Usually must open the area
Greywoode JD, Pribitkin EA, Krein H. Fac Plas Surg, 2010.
If It Works, Great
Brickman K, Adams DZ, et al. Clin J Sport Med, 2012.
Must Keep Fluid From Reaccumulating
Kakarala K, Kieff DA, Laryngoscope, 2012.Roy S, Smith LP. Am J Otolaryngol, 2010.
Delay = Cauliflower Ear
Hard to Repair
Fujiwara M, Suzuki A, et al. J Plast Recon Aesth Surg, 2011.
Cefdinir and Red Stool
Mookadam M, Eisenhart A. Ann Emerg Med, 2009.
Cefdinir-Associated Red Stool
• Benign process caused by medication-iron complex
• 10% incidence?• Should be heme-negative• Do not need to stop or avoid medication
Graves R, Weaver SP. J Am B Fam Med, 2008.