Common pediatric surgery problems.pdf
Common pediatric surgery problems.pdf
Common pediatric surgery problems.pdf
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COMMON PEDIATRIC<br />
SURGERY PROBLEMS<br />
Surgery Curriculum Conference<br />
June 13, 2012
Case 1<br />
39 week gestational age<br />
Normal pregnancy and vaginal delivery<br />
Apgars 9 1, 10 5<br />
Started breastfeeding and started to have multiple<br />
episodes of bright yellow/green emesis
Prenatal work-up<br />
Trisomy 21<br />
Normal ultrasound at 18weeks<br />
Mom has negative serologies
Case 1<br />
Clinical examination<br />
HR 160, RR 40, BP 80/50<br />
O2 sats 100% room air<br />
HEENT: macroglossia, epicanthic fold of the eyelid,<br />
upslanting palpebral fissures<br />
Chest: Good AE=AE<br />
Cardiac: holosystolic III/VI murmur, normals S1, S2<br />
Abdomen: non distended, soft, nontender, no erythema, no<br />
HSM<br />
Normal female genitalia<br />
MSK/Neuro: Simian crease, slight decreased muscle tone.
Case 1<br />
Investigations<br />
Bloodwork<br />
Imaging<br />
Any other diagnostic tests?
ECHO<br />
VSD<br />
Normal BMP, CBC, neg cultures
Neonatal Emesis DDx<br />
Upper GI<br />
Duodenal atresias/webs<br />
small bowel atresias<br />
malrotation/midgut volvulus<br />
GERD<br />
Meconium ileus<br />
pyloric stenosis<br />
Inguinal hernia<br />
NEC
Neonatal Emesis DDx<br />
Lower GI<br />
Colonic atresia<br />
Meconium plug<br />
Hirschsprung’s<br />
Small Left Colon Syndrome<br />
Microcolon-Intestinal Hypoperistalsis Syndrome<br />
Imperforate anus
Neonatal Emesis DDx<br />
Medical causes<br />
Sepsis<br />
Metabolic disorders<br />
Hypothyroidism<br />
Electrolyte disturbances<br />
GERD
Radiological workup<br />
KUB/Cross-table lateral<br />
Contrast enemas for distal obstructions<br />
UGI for malrotation/proximal atresias
Duodenal atresia<br />
Management<br />
NGT<br />
Resuscitate<br />
Surgical approach<br />
duodenoduodenostomy
Which of the following is TRUE regarding duodenal<br />
atresia?<br />
A. It is associated with trisomy 21 in 10% cases.<br />
B. Abdominal X-ray is usually normal.<br />
C. Results from disruption of fetal blood supply.<br />
D. Operative repair involves duodenal resection.<br />
E. Concomitant abnormalities can include annular pancreas,<br />
esophageal atresia, or VACTERL lesions.
Which of the following is TRUE regarding duodenal<br />
atresia?<br />
A. It is associated with trisomy 21 in 10% cases.<br />
B. Abdominal X-ray is usually normal.<br />
C. Results from disruption of fetal blood supply.<br />
D. Operative repair involves duodenal resection.<br />
E. Concomitant abnormalities can include annular pancreas,<br />
esophageal atresia, or VACTERL lesions.
Duodenal atresia
Duodenal Atresia<br />
Failure to recanalize lumen of duodenum after<br />
solid phase of embryologic development<br />
Distal atresias are due to vascular events<br />
Associated with Down’s syndrome in 30%<br />
Atresia seen in 10% of Down’s patients<br />
Vomiting can be bilious or non-bilious<br />
Abdominal X-ray shows “double-bubble”<br />
Best repaired by bypass -><br />
duodenoduodenostomy or duodenojejunostomy<br />
no indication to divide annular pancreas
Case 2<br />
2 day old infant in newborn nursery<br />
Sent to NICU for evaluation of bilious emesis
Physical Examination<br />
HR 165, RR 50, O2 sats 98 RA<br />
HEENT<br />
Normal oropharynx<br />
Chest<br />
Clear, AE=AE<br />
Cardiac<br />
Normal HS, good peripheral pulses<br />
Abdo<br />
Nondistended, generalized tenderness<br />
Soft, no discoloration, no masses, no HSM<br />
No inguinal hernias
Work-up<br />
Bloodwork<br />
Imaging
Normal embryologic rotation
Abnormal rotation and nonfixation
Management of Malrotation/volvulus<br />
Resuscitate<br />
Urgent <strong>surgery</strong>
Steps to correcting malrotation<br />
1. Entry into abdominal cavity and evisceration (open)<br />
2. Counterclockwise detorsion of the bowel (acute<br />
cases)<br />
3. Division of Ladd’s cecal bands<br />
4. Broadening of the small intestine mesentery<br />
5. Incidental appendectomy<br />
6. Placement of small bowel along the right lateral<br />
gutter and colon along the left lateral gutter
Ladd Procedure
Malrotation<br />
Occurs in 1/200 – 1/500 live births<br />
Symptomatic in 1/6000 live births<br />
30-62% have associated anomaly<br />
Up to 75% present w/in 1st month of life<br />
Classic presentation is infant with bilious emesis<br />
May present as pain, duodenal obstruction,<br />
malnutrition, acute abdomen/shock
Malrotation<br />
Due to abnormal fixation of midgut to<br />
retroperitoneum – leads to narrow base of<br />
mesentery which can easily twist<br />
Ladd Procedure<br />
Reduce volvulus by rotating counterclockwise<br />
Division of Ladd’s bands between cecum and<br />
duodenum/right gutter<br />
Division of adhesions to widen mesentery<br />
Run bowel to r/o obstructions<br />
Appendectomy<br />
Place bowel in nonrotated position
Case 3<br />
2 day old infant in NICU 3<br />
Consulted for abdominal distention and bilious<br />
emesis<br />
Work-up and differential
Pathophysiology of intestinal atresias<br />
How would you confirm diagnosis and what would<br />
you see<br />
Classification scheme
Case 4<br />
3 day old infant<br />
Failure to pass stools, abdominal distention and<br />
bilious emesis<br />
Work-up and differential
What other tests should be done<br />
Sweat test for CF<br />
Genetic testing for CFTR gene mutation
Which of the following is FALSE regarding meconium<br />
ileus?<br />
A. Underlying diagnosis is usually cystic fibrosis.<br />
B. Most often requires operative intervention.<br />
C. Presents as a neonatal bowel obstruction.<br />
D. X-rays may reveal a stippled pattern in the RLQ (“soap<br />
bubble” sign).<br />
E. May be relieved by water-soluble contrast enema.
Which of the following is FALSE regarding meconium<br />
ileus?<br />
A. Underlying diagnosis is usually cystic fibrosis.<br />
B. Most often requires operative intervention.<br />
C. Presents as a neonatal bowel obstruction.<br />
D. X-rays may reveal a stippled pattern in the RLQ (“soap<br />
bubble” sign).<br />
E. May be relieved by water-soluble contrast enema.
Meconium Ileus<br />
Newborn bowel obstruction secondary to<br />
inspissated meconuim in distal ileum<br />
Enema reveals microcolon -> may be therapeutic<br />
Non-operative management successful in 2/3<br />
OR required for perforation or failed enema<br />
may flush bowel with N-acetylcysteine in saline
Management<br />
Fluid resuscitaion<br />
Gastric decompression<br />
Pulmonary support as needed<br />
Contrast enema with water soluble contrast<br />
Failure of nonoperative management<br />
Surgery<br />
2-4% NAC, 50% hyperosmolar agent via appendix<br />
Alternative surgical techniques involve resection, anastomosis, and<br />
temporary enterostomy through which postoperative irrigations<br />
may be delivered
Simple vs Complicated meconium ileus<br />
Complicated<br />
Volvulus<br />
Perforation resulting in meconium peritonitis<br />
adhesive meconium peritonitis<br />
giant cystic meconium peritonitis or pseudocyst<br />
meconium ascites<br />
infected meconium peritonitis
Case 5<br />
An 8 hr old infant drools and spits up his first feed. A<br />
tube is passed into the esophagus and a film is<br />
obtained.<br />
What is the diagnosis?
Esophageal Atresia and<br />
Tracheoesophageal Fistula<br />
Incomplete partitioning of primitive foregut<br />
5 types of atresias<br />
Esophageal atresia with distal TEF most common<br />
8% 1% 85% 2% 4%
Esophageal Atresia and<br />
Tracheoesophageal Fistula<br />
Can be part of VACTERL anomalies<br />
vertebral, anal, cardiac, TEF, renal, limb<br />
Atresias detected by inability to pass NGT/OGT<br />
TEF w/o atresia presents with recurrent aspiration<br />
Low-risk infants should get primary repair<br />
long gap (>3 vertebral bodies) repair is delayed<br />
high-risk babies get gastrostomy<br />
Post-op complications include esophageal leak,<br />
dysmotility, GE reflux, strictures
Case 6<br />
A listless 9-month-old boy presents with acute onset<br />
of severe intermittent abdominal pain. Rectal<br />
exam is guaiac positive. What is the most likely<br />
diagnosis?<br />
A. Meckel’s diverticulum.<br />
B. Acute appendicitis.<br />
C. Intussusception.<br />
D. Intestinal polyp.<br />
E. Gastritis.
A. Meckel’s diverticulum.<br />
B. Acute appendicitis.<br />
C. Intussusception.<br />
D. Intestinal polyp.<br />
E. Gastritis.
Intussusception<br />
<strong>Common</strong>ly affects children 3 months to 2 yrs<br />
severe crampy abdominal pain (every 10-20 minutes)<br />
vomiting, “currant jelly” stools<br />
tender, sausage-like mass in RUQ<br />
Telescoping of terminal ileum into large intestine<br />
Contrast enema for diagnosis will reduce 80%<br />
air pressure to 120 mmHg, barium to 100 cm H 2O<br />
10% recurrence, often within hours<br />
OR reduction if not reduced radiographically<br />
5% of patients need resection
Intussusception<br />
Plain AXR<br />
Look for gas in cecum<br />
Abdominal ultrasound – look for target
Which of the following statements is TRUE with respect<br />
to neonatal abdominal wall defects?<br />
A. The bowel in omphalocele is covered by a sac.<br />
B. Gastroschisis is frequently associated with other anomalies.<br />
C. A Silastic silo is rarely employed in management of these<br />
defects.<br />
D. Mortality is higher in gastroschisis.<br />
E. Operative management of omphalocele usually requires<br />
bowel resection.
Which of the following statements is TRUE with respect<br />
to neonatal abdominal wall defects?<br />
A. The bowel in omphalocele is covered by a sac.<br />
B. Gastroschisis is frequently associated with other anomalies.<br />
C. A Silastic silo is rarely employed in management of these<br />
defects.<br />
D. Mortality is higher in gastroschisis.<br />
E. Operative management of omphalocele usually requires<br />
bowel resection.
Omphalocele<br />
Occur 1 in 5000 live births, more common in boys<br />
over 50% have associated cardiac, GI, GU,<br />
musculoskeletal, or CNS anomalies<br />
Herniation of abdominal contents through defective<br />
umbilical ring<br />
overlying sac of outer amnion and peritoneum<br />
umbilical cord in continuity with sac<br />
liver involved in larger defects<br />
High mortality (30-60%) due to other anomalies
Omphalocele
Omphalocele<br />
Non-operative management with escharotic agent<br />
OR for reduction and closure of abdominal wall<br />
keep intra-abdominal pressure < 20 mmHg<br />
large defects require skin flap or prosthetic<br />
Silastic silo most common, reduce daily for 3-10 days<br />
Post-op complications include sepsis, GE reflux,<br />
inguinal hernias, abdominal wall hernia
Gastroschisis<br />
Anterior abdominal wall defect (“belly cleft”)<br />
usually to right of umbilical cord<br />
no sac or membrane covering contents<br />
exposed bowel thick, edematous, exudative peel<br />
associated intestinal atresias in 10%<br />
Initial management<br />
aggressive fluid replacement (2-3X normal)<br />
protection of exposed bowel w/occlusive dressing
Uterus +<br />
Fallopian Tube<br />
Bladder<br />
Small bowel<br />
Colon<br />
Stomach
Gastroschisis<br />
Primary reduction and closure in 80-90% cases<br />
Silastic silo if high intra-abdominal pressure<br />
may require resection if exposed bowel non-viable<br />
Post-op complications:<br />
abdominal compartment syndrome<br />
sepsis<br />
necrotizing enterocolitis<br />
abdominal wall cellulitis<br />
prolonged ileus<br />
short gut syndrome w/ TPN dependence
Case 7<br />
3. A 1.5 kg, 30-wk preemie develops abdominal distention<br />
and bloody stool after 1st feedings. Which of the following is<br />
TRUE regarding his condition?<br />
A. Supportive treatment includes stopping all feeds, NGT<br />
drainage, IVF, serial abdominal exams and radiographs.<br />
B. IV antibiotics not indicated unless pathogen identified.<br />
C. Barium enema is the imaging modality of choice.<br />
D. Overall mortality reported as 50-60%.<br />
E. Intestinal stricture formation is rare.
Case 7<br />
A. Supportive treatment includes stopping all feeds, NGT<br />
drainage, IVF, serial abdominal exams and radiographs.<br />
B. IV antibiotics not indicated unless pathogen identified.<br />
C. Barium enema is the imaging modality of choice.<br />
D. Overall mortality reported as 50-60%.<br />
E. Intestinal stricture formation is rare.
Necrotizing Entercolitis (NEC)<br />
Idiopathic mucosal intestinal injury, may progress to<br />
transmural necrosis<br />
1/2 patients < 1500 g (7% incidence), 80% < 2500 g<br />
at birth<br />
90% in premature neonates
Necrotizing Entercolitis (NEC)<br />
Signs:<br />
feeding intolerance<br />
vomiting<br />
abdominal distention<br />
progressive sepsis<br />
autonomic instability (Apneas and Bradys)<br />
abdominal wall erythema +/- mass<br />
Labs:<br />
metabolic acidosis<br />
thrombocytopenia
X-rays:<br />
Necrotizing Enterocolitis (NEC)<br />
distended loops c/w ileus,<br />
pneumatosis intestinalis<br />
May appear normal or<br />
mild ileus at first<br />
Progression demonstrates<br />
portal venous air<br />
(pathognomonic)
Necrotizing Enterocolitis (NEC)<br />
Pathogenesis<br />
No single predisposing factor<br />
Prevention<br />
Breast milk
Necrotizing Enterocolitis (NEC)<br />
Medical Treatment<br />
NPO, NGT, TPN<br />
AXR q 8 hr<br />
Usually necessitates <strong>surgery</strong> within 24 hr or not at all<br />
NPO for 10 to 14 days after radiographic evidence of<br />
disease has abated<br />
Broad spectrum Abx<br />
Bacterial translocation<br />
Amp/Gent/Clinda or Flagyl
Necrotizing Enterocolitis (NEC)<br />
Indications for OR are free air (absolute), fixed<br />
abdominal mass, abdominal wall erythema, failure<br />
to improve (controversial)<br />
OR for resection of dead bowel, formation of stomas<br />
“second-look laparotomy” 24-48 hrs if needed<br />
Peritoneal drainage<br />
Overall mortality 20-40%<br />
Long term complications of strictures, short bowel<br />
syndrome
Case 8<br />
4. A full-term newborn has not passed meconuim by DOL 2.<br />
Which of the following is FALSE regarding his likely diagnosis?<br />
A. It is more common in males.<br />
B. Suction rectal biopsy is rarely adequate for diagnosis.<br />
C. Enterocolitis is a significant cause of mortality.<br />
D. Disease is most often confined to the distal colon.<br />
E. Barium enema may be normal.
Case 8<br />
A. It is more common in males.<br />
B. Suction rectal biopsy is rarely adequate for diagnosis.<br />
C. Enterocolitis is a significant cause of mortality.<br />
D. Disease is most often confined to the distal colon.<br />
E. Barium enema may be normal.
Hirschsprung’s Disease<br />
Absence of ganglia in submucosal and myenteric<br />
plexuses<br />
variable proximal extension of aganglionosis<br />
lack of peristalsis and failure of sphincter relaxation<br />
rectosigmoid only in 75%, entire colon in 8%<br />
1:5000 births<br />
70 – 80% boys<br />
4X greater in Down’s babies
Hirschsprung’s Disease<br />
Presents as failure to pass meconium w/in 24 hrs or<br />
constipation in older child<br />
Diagnosis best made by rectal biopsy<br />
suction adequate if submucosa present<br />
Rectal biopsy<br />
Anorectal manometry
Hirschsprung’s Disease<br />
OR requires biopsies to confirm ganglion cells in<br />
normal bowel<br />
“Pull-through” operations<br />
Swenson: complete excision, anastamosis to proximal<br />
anal canal at columns of Morgagni<br />
Soave: endorectal mucosal excision, pull through rectal<br />
muscular sleeve<br />
Duhamel: retains portion of aganglionic bowel<br />
anteriorly using GIA stapler
Hirschsprung’s Disease
Hirschsprung’s Disease<br />
Ganglion cells
Hirschsprung’s Disease<br />
1. Absence of<br />
ganglion cells<br />
2. Hypertrophic nerve<br />
trunks
Hirschsprung’s Disease<br />
Swenson Soave Duhamel
Hirschsprung’s Disease<br />
Enterocolitis<br />
12 – 58%<br />
? Fecal stasis<br />
Life threatening<br />
Treat with rectal irrigation and flagyl
Case 9<br />
Newborn infant, 36 week gestational age,<br />
delivered for PROM<br />
No prenatal care<br />
Significant respiratory distress at birth requiring<br />
emergent intubation<br />
Apgars 2 and 5
Case 9<br />
Decreased breath sounds on the left side<br />
Scaphoid abdomen<br />
Workup?
Congenital Diaphragmatic Hernia
CDH<br />
Primary physiologic<br />
disturbance:<br />
pulmonary hypoplasia<br />
Pulmonary hypertension<br />
most important (reversible)<br />
Prenatal:<br />
Polyhydramnios<br />
Interventions<br />
Not proven to improve<br />
outcomes
CDH – Post natal Treatment<br />
Gentle ventilation<br />
nitric oxide<br />
surfactant<br />
high frequency, oscillating ventilation<br />
muscle paralysis, induced alkalosis<br />
spontaneous respiration, permissive hypercapnea<br />
perfluorocarbon ventilation<br />
combinations of the above<br />
extracorporeal life support<br />
SURGERY – once physiolgically stable
ECMO CANNULATION
ECMO CANNULATION<br />
VENO-ARTERIAL CANNULATION
ECMO CANNULATION<br />
VENO-VENOUS CANNULATION
ECMO Circuit
CDH - Survival<br />
Prognosis:<br />
Pulmonary recovery: Overall reported survival varies<br />
among institutions. When all resources, including<br />
ECMO, are provided, survival rates range from 40-<br />
69%.<br />
Long-term morbidity: Significant long-term morbidity,<br />
including chronic lung disease, growth failure,<br />
gastroesophageal reflux, and neurodevelopmental<br />
delay, may occur in survivors.
Case 10<br />
A 5-wk-old boy presents with 3 days of non-bilious projectile<br />
vomiting and dehydration. Which of the following is TRUE<br />
about his condition?<br />
A. Immediate laparotomy is warranted.<br />
B. UGI series is the diagnostic procedure of choice.<br />
C. Delay in diagnosis leads to metabolic acidosis.<br />
D. Most commonly seen in females.<br />
E. Fluid replacement consists of ½ NS + KCL
A 5-wk-old boy presents with 3 days of non-bilious projectile<br />
vomiting and dehydration. Which of the following is TRUE<br />
about his condition?<br />
A. Immediate laparotomy is warranted.<br />
B. UGI series is the diagnostic procedure of choice.<br />
C. Delay in diagnosis leads to metabolic acidosis.<br />
D. Most commonly seen in females.<br />
E. Fluid replacement consists of ½ NS + KCL
Pyloric Stenosis<br />
1 in 600 births, male: female ratio 4:1, 3-12<br />
weeks<br />
Gastric outlet obstruction due to hypertrophy of<br />
pyloric muscle<br />
Progressive, projectile non-bilious vomiting<br />
Hypochloremic, hypokalemic metabolic alkalosis<br />
renal compensation for hypovolvemia<br />
Ultrasound is diagnostic procedure of choice<br />
thickness > 5 mm, channel length > 15 mm<br />
Repair via Fredet-Ramstedt pyloromyotomy
Pyloromyotomy
Case 11<br />
A 6-wk-old infant presents with jaundice. A sonogram<br />
appears normal. HIDA scan fails to demonstrate emptying<br />
into the duodenum. What is the next best step in<br />
management?<br />
A. List for liver transplant.<br />
B. Follow closely until 3 months of age, then do Kasai.<br />
C. Percutaneous liver biopsy.<br />
D. Initiate anti-inflammatory therapy.<br />
E. Laparotomy with operative cholangiogram and liver<br />
biopsy, then Kasai if warranted.
A 6-wk-old infant presents with jaundice. An abdominal<br />
USG appears normal. HIDA scan fails to demonstrate<br />
emptying into the duodenum. What is the next best step in<br />
management?<br />
A. List for liver transplant.<br />
B. Follow closely until 3 months of age, then do Kasai.<br />
C. Percutaneous liver biopsy.<br />
D. Initiate anti-inflammatory therapy.<br />
E. Laparotomy with operative cholangiogram and liver<br />
biopsy, then Kasai if warranted.
Biliary Atresia<br />
Fibrous obliteration of extrahepatic bile ducts<br />
1 in 10-15 thousand births<br />
Jaundice, conjugated hyperbilirubinemia, firm<br />
hepatomegaly due to biliary cirrhosis<br />
Lab work up should include LFTs, Alpha-1 antitrypsin,<br />
TORCH infections, sweat test, hepatitis<br />
Sono shows no extrahepatic ducts, tiny gallbladder<br />
HIDA scan reveals no emptying into the duodenum<br />
Liver biopsy reveals cholestasis and bile duct<br />
proliferation
Kasai Portoenterostomy<br />
Roux-en-Y limb of jejenum sutured to porta where<br />
atretic bile ducts exit hepatic parenchyma<br />
Results depend on age (10 weeks), anatomy and<br />
histology of atretic bile ducts, ? degree of cirrhosis<br />
overall:<br />
1/3 fail immediately<br />
Long term survival in 25% of those that have drainage<br />
Results of liver transplantation not affected by Kasai<br />
procedure
Biliary Atresia
Biliary Atresia
Kasai Portoenterostomy
Congenital Lung lesions<br />
Which statement is FALSE regarding extrapulmonary<br />
sequestration?<br />
• A. The parenchyma is not connected to the<br />
tracheobronchial tree<br />
• B. Arterial blood supply is systemic<br />
• C. Venous blood supply is pulmonary<br />
• D. Most frequently in males<br />
• E. <strong>Common</strong>ly associated with other anomalies
Which statement is FALSE regarding extrapulmonary<br />
sequestration?<br />
• A. The parenchyma is not connected to the<br />
tracheobronchial tree<br />
• B. Arterial blood supply is systemic<br />
• C. Venous blood supply is pulmonary<br />
• D. Most frequently in males<br />
• E. <strong>Common</strong>ly associated with other anomalies
Congenital Pulmonary Airway<br />
Malformation
Pulmonary Sequestration<br />
Cystic mass of nonfuctioning primitive lung tissue<br />
not connected to tracheobronchial tree<br />
Extrapulmonary<br />
usually diagnosed in first year due to other anomalies<br />
Intrapulmonary (90%)<br />
Usually diagnosed later childhood/adolescence<br />
Males 3-4:1<br />
Systemic arterial supply – 95%<br />
Systemic venous drainage – >80%
Pulmonary Sequestration<br />
Usually located b/w LLL and diaphragm<br />
Extrapulmonary may also be found connected to gi<br />
tract<br />
Associated anomalies – 65%<br />
Pulmonary hypoplasia 25%, CDH 16%
Congenital Lobar Emphysema<br />
Air trapped in the lobe<br />
Leads to adjacent lobe atelectasis<br />
Shifts mediastinum to opposite side<br />
More common in the upper lobes<br />
CXR for diagnosis<br />
Nonop management – low vent pressure/volume,<br />
positioning<br />
Resection provides definitive treatment
PEDIATRIC HEAD AND<br />
NECK MASSES
Case 1<br />
18mos old female<br />
Presents to your office with a mass above her left<br />
eyebrow<br />
What next?<br />
Differential diagnosis
Evaluation of mass<br />
H&P<br />
Age<br />
Onset<br />
Rapidity of growth<br />
Fluctuation in size<br />
Pain<br />
Infection<br />
Trauma<br />
Travel<br />
Exposure<br />
PE<br />
Size<br />
Multiplicity<br />
Laterality<br />
Consistency<br />
Color<br />
Mobility<br />
Tenderness<br />
Fluctuation
Case 1
Differential diagnosis
Differential Diagnosis<br />
Congenital<br />
Branchial cleft cysts<br />
Thyroglossal duct cyst<br />
Dermoid cyst<br />
Vascular malformation<br />
Lymphatic<br />
Hemangioma<br />
Teratoma<br />
Bronchogenic cyst<br />
Thymic cyst<br />
Myelomeningocele<br />
Inflammatory lesions<br />
Reactive lymphadenopathy<br />
Granulomatous disease<br />
Atypical mycobacteria<br />
Cat scratch disease<br />
Toxoplasmosis<br />
Sarcoid<br />
Suppurative lymphadenitis<br />
Noninflammatory benign<br />
Inclusion cyst<br />
Fibromatosis<br />
Keloid
Differential Diagnosis<br />
Benign neoplasms<br />
Neurofibroma<br />
Lipoma<br />
Paraganglioma<br />
Goiter<br />
Thyroid nodule<br />
Malignant Neoplasm<br />
Lymphoma<br />
Hodgkins<br />
NonHodgkins<br />
Thyroid Carcinoma<br />
Sarcoma<br />
Neuroblastoma
Case 2<br />
2 year old male<br />
Mass on side of neck<br />
Noticed recently and slowly has increased in size<br />
One episode where it was erythematous and tender<br />
Treated with antibiotics and resolved
Case 2<br />
Mass is anterior to sternoclavicular musle<br />
Less than 5 mm<br />
Small skin opening
Branchial cleft anomalies
Branchial cleft anomalies
Branchial arches
Case 3<br />
12 year old girl<br />
Mass in the anterior neck
Case 3
An 8 y.o. boy has a recurrent painful swelling in a 2cm<br />
mass in the midline of his neck below the hyoid bone.<br />
Which is TRUE?<br />
A. Ectopic thyroid is present in 50% of cases<br />
B. surgical excision includes the pyramidal lobe of the thyroid<br />
C. the structure originates at the foramen cecum<br />
D. Fistula tracts drain laterally at the inferior border of the<br />
sternoclaidomastoid<br />
E. Simple excision can be done with local anesthesia
An 8 y.o. boy has a recurrent painful swelling in a 2cm<br />
mass in the midline of his neck below the hyoid bone.<br />
Which is TRUE?<br />
A. Ectopic thyroid is present in 50% of cases<br />
B. surgical excision includes the pyramidal lobe of the thyroid<br />
C. the structure originates at the foramen cecum<br />
D. Fistula tracts drain laterally at the inferior border of the<br />
sternoclaidomastoid<br />
E. Simple excision can be done with local anesthesia
Thyroglossal Duct Cyst<br />
Arise from duct formed when developing thyroid<br />
passes from lingual foramen cecum through/near<br />
hyoid bone to neck<br />
Most common midline neck mass in kids<br />
May be lateral (within 2cm) in 25% of cases<br />
Can extend to pyramidal lobe<br />
Contain aberrant thyroid tissue in 1%
Thyroglossal Duct Cyst<br />
May contain papillary or mixed papillary/follicular<br />
adenocarcinoma in 1%<br />
Sistrunk procedure<br />
Excise entire duct to level of foramen cecum, including<br />
part of hyoid bone to prevent recurrence<br />
Periop antibiotics unnecessary, 4% infection rate
Sistrunk
Sistrunk
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