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.