Objectives. Bits and Pieces: Developmental Remnants in the ED. Case 1. Evelyn Porter, MD November 14, Refresh your memory.

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1 Bits and Pieces: Developmental Remnants in the ED Evelyn Porter, MD November 14, 2012 Refresh your memory Review management Case based format Objectives Case 1 4 year old boy presents to the ED with an area of redness and swelling adjacent to his left ear for 4 days. He has had this before and it usually goes away with antibiotics but this time it got worse. He has an appointment with ENT in 1 week but could not wait until then. He denies trauma, fever, headaches, hearing changes, sick contacts or other lesions 1

2 Preauricular Pit AKA sinus, fistula, tract, cyst Incidence of 1% Most are unilateral and on the right Inherited and sporadic Rarely associated with syndromes Preauricular Pit Preauricular Pit Treatment: I and D with cultures Antibiotics staph coverage Disposition: Home ENT follow up Open excision Ahuja AT et al. Clinical Radiology Ellies et al. J Oral Maxillofac Surg Scheinfeld et al. Pediatr Dermatol.2004 Scheinfeld et al. Pediatr Dermatol

3 Case 2 Thyroglossal Duct Cyst 3 yo male presents with an asymptomatc neck mass. The child had no significant medical or surgical history, immunizations were up to date. PE: Prominent 2x2 cm neck mass, just lateral to to the midline, painless to palpation, readily moveable, no discharge was present Developmental remnant of thyroid gland Most common congenital neck mass Mean age 6 years Historical & Physical exam features: Midline neck mass at level of hyoid Moves with the tongue Intermittent enlargement with URI s Brown DK.Clinical Pediatrics Thyroglossal Duct Cyst Thyroglossal Duct Cyst Differential diagnosis: Congenital Neoplastic Inflammatory Complications: Infection Inflammation Fistula Disposition: Home ENT follow up Treatment: Operative Excision Turkyilmaz et al. Pediatric International

4 Case 3 Case 3 HPI: Red, painful, enlarging mass ROS: Cough, rhinorrhea, low grade fevers Inflamed Thyroglossal Duct Cyst Rely on history & physical? Imaging? Ultrasound vs CT Imaging in the Evaluation of Inflammatory Neck Mass Ultrasound Sensitivity 65%, Specificity 88% Consult? Douglas. Clin Otolaryngol

5 Imaging in the Evaluation of Inflammatory Neck Mass Ultrasound Sensitivity 65%, Specificity 88% Repeat Ultrasound: Sensitivity 100% Imaging in the Evaluation of Inflammatory Neck Mass Ultrasound Sensitivity 65%, Specificity 88% Repeat Ultrasound: CT Sensitivity 100% Sensitivity 90%, Specificity 70 s-90 s% False positive rate up to 20% Quraishi MS et al. Clin. Otolaryngol Wetmore RF. Otolaryngol Head Neck Surg Elden L. J Otolaryngol Imaging in the Evaluation of Inflammatory Neck Mass Ultrasound Thyroglossal Duct Cyst Sensitivity 65%, Specificity 88% Repeat Ultrasound: Sensitivity 100% CT Sensitivity 90%, Specificity 70 s-90 s% False positive rate up to 20% Ultrasound vs CT Uncomplicated: Outpatient ENT Complicated: Antibiotics Ultrasound+/- CT Ultrasound was sufficient in 97% of cases CT changed management in 16% of cases Rozovsky K. Eur Radiol

6 Case 4 A 4 day old infant presents with a chief complaint of vaginal mass. The mother noticed it while in the hospital but thought it was normal. The grandmother noticed the mass while caring for the child on day 3 of life and encouraged the mother to goto the ER. The girl was delivered via NSVD to a G1 P0 mother who had received no prenatal care. The child appears comfortable, is exclusively bottle fed, with normal urinary and bowel habits. The ROS and physical exam are otherwise unremarkable. Case 5 14 year old girl presents with severe low abdominal pain, off an on for 1 year but worse over the past few months. The pain usually responds to ibuprofen but today she got no relief. She denies nausea, fever, dysuria, diarrhea and menarche Physical Exam: Abdomen: + bowel sounds, tenderness across lower abdomen, no rebound no guarding, no palpable mass 6

7 Imperforate Hymen Imperforate Hymen Incidence 1% Most common cause of congenital vaginal obstruction Bimodal age distribution History & physical: Amenorrhea in patient with secondary sexual characteristics Cyclical abdominal/pelvic pain caused by hematocolpos Back pain Urinary retention Differential Diagnosis: Gynocologic Urologic GI Neoplastic Work up: Ultrasound Treatment: Neonate:Watchful waiting Teen: Operative, estrogen Morbidity is rare Nazir. Pediat Surg Int Nazi et al. Pediatr Surg Int Case 4 Imperforate Hymen - Infant Ultrasound of the kidneys and uterus were normal Vaginal bulge had resolved at 2 month check up Defer surgery Case 5 Imperforate Hymen - Teen Ultrasound: Large cystic structure measuring 11.4 x 17.3 x 10.5 cm in the lower pelvis that likely represents a markedly distended vagina. Uterus, and ovaries appear normal OR: Transection of imperforate hymen, drainage of the hematocolpos 7

8 Case 6 HPI: 6 day old boy brought to a community ED in shock. He presents with a 1 day history of periumbilical erythema and irritability. One day prior he was seen by his pediatrician because of mild periumbilical erythema and was started on an unknown topical antibiotic. Worsening erythema prompted todays visit. PMHx: Full Term to G1 P0, +prenatal care, NSVD, birthweight 3kg Omphalitis Omphalitis Infection of umbilical stump Incidence <1% in developed countries Up to 6% in developing countries! Risk factors: preterm birth, unsterile delivery, PROM, maternal infection, low birth weight, umbilical catheters Cultural practices Exam findings: Periumbilical edema Periumbilical erythema Umbilical/Periumbilical tenderness Umbilical discharge Sawardekar. pediatr Infect Dis Fraser N et al. Acta Pediatrica

9 Omphalitis Umbilical Cord Care Surgical emergency!!! Treatment: IV antibiotics +/-debridement Staph, Strep, E.coli, Klebsiella, Proteus, Tetanus Complications: Abdominal wall, intra-abdominal spread, septic emboli Falls of around 1 week May have spotting at the sight of detachment Dry care is recommended: No benefit to using alcohol or topical antibiotics Disposition: Admit all for iv antibiotics Kapellen et al. Neonatology Dore et al. J Obstet Gynecol Neonatal Nurs.1998 Worl Health Organization. Care of the umbilical chord.1999 Case 6 Continued Summary Hospital course: Blood and umbilical cultures, broad spectrum IV antibiotics Seizures Respiratory failure -> Mechanical ventilation Fasciotomy of abdominal wall Death due to severe sepsis on hospital day 2 Preauricular pits: Drain if infected Thyroglossal duct cyst: ENT follow up Imperforate hymen: Watch newborns, treat teens Meckel s Diverticulum: If high suspicion, keep looking Omphalitis: Surgical emergency Manikoth P et al. Lancet

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