clinical pearls

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.