clinical pearls
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Clinical Pearls. Eric D. Baum, MD Connecticut 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 - PowerPoint PPT PresentationTRANSCRIPT
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.