When to refer to ENT:Lumps, bumps, and others.

David J. Brown, M.D.

Associate ProfessorDivision of Pediatric Otolaryngology

Interim Associate Vice President and Associate Dean for Health Equity and Inclusion

Epistaxis

Proper technique of stopping nose bleeds

Nasal blood vessel anatomy

Nose bleed maintenance

• Keep moist– Humidifier– Nasal saline– Ointment along septum

• Keep fingers out of nose• Trim fingernails

• Can refer if these measures don’t work, significant bleeding, and/or parents want to consider nasal cautery

Juvenile nasopharyngeal angiofibroma

• In males• Usually teenage• Extensive bleeding• May have nasal obstruction• May have CN V sensory deficits

Congenital Nasal Masses- Dermoid

Midline nasal masses

• Dermoid• Glioma• Encephalocele

• May extend intracranial• Therefore, NEVER

biopsy or cut open before obtaining a scan.

Parotitis

Congenital and Vascular Anomalies

• Branchial cleft cyst• Thyroglossal duct

cyst• Laryngocele• Hemangioma• AVM• Lymphatic

malformation

Hemangioma

• Beard distribution has high risk of subglottic hemangioma

• High likelihood of having airway issues

• May need a trach

Congenital AnomaliesThyroglossal Duct Cyst

Branchial Cleft Anomalies

Second most common head and neck congenital lesion

20% of congenital cervical masses in children

1% are bilateral

Thought to occur secondary to incomplete obliteration of the branchial clefts and pouches during embryogenesis

Second: 40-95%First: 5-25%Third/Fourth: 2-8%

Case 4 yo girl presents with postauricular mass.Had been infected twice and I&D performed at OSH EDPE: Post-auricular non-tender cystic mass. DX: First BCC

First Branchial Cleft

Presentation: Retroauricular, parotid, cervical (below mandible and above hyoid)Enlarging mass after infection with associated erythema and pain.Cervical lesions may have a pit-like depressionTract can extend to EAC with drainage

Evaluation:Imaging- MRI or CT

Treatment: Surgical Excision

First Branchial Clefts

Second branchial cleft fistulaPresentation: neck pit anterior to SCM that may drainFollows the embryologic course in between IC and EC, over CNs 12 and 9 andInto tonsillar fossaCan end blindly (sinus tract)Treatment is excision with one or two incisions+/- Tonsillectomy

Second Branchial Cleft Cyst

Presentation: Cystic neck massEvaluation: CTTreatment: Antibiotics and I&D if acutely infected. Excision when not infected

Third Branchial Cleft Cyst

CT Scan

Endoscopic view of left pyriform sinus

Left hemi-thyroidectomy and removal of tract

Preauricular Pit

May have FH of pits

Can be associated with Branchio-oto-renal syndrome

If concerns for hearing loss orRenal problems, get audiogram and renal ultrasound.

Most present as isolated pits, without syndromic association.

Infected Preauricular Pit

STRIDOR• Laryngomalacia is the most

common cause of infantile stridor and represents over 75% of the cases.

• inspiratory stridor caused by collapse of the epiglottis and arytenoid mucosa.

• high-pitched musical or a low-pitched, course, fluttering stridor

• stridor may initiated or exacerbated by agitation, feeding or while lying in the supine position.

• Associated with GERD

Indications for stridor referral

• Respiratory distress

• Failure to thrive

• Dysphagia

• Aspiration

Supraglottoplasty with Sinus Instruments

Microdebrider to remove extra arytenoid mucosa

Laryngeal cysts

• mucous retention cysts that present with stridor, respiratory distress, cyanosis, dysphagia, failure to thrive, or ALTE.

Vallecular cystTreatment – marsupilizationSymptoms resolve quickly aftersurgery

Subglottic cystFrom intubation traumaCan occur MONTHS after intubationTreatment- excision. High recurrence

Vocal Fold Paralysis

• 2nd most common cause of stridor in neonates• CNS anomalies

– Arnold-Chiari malformations, hydrocephalus, and myelomeningocele

– pressure on the vagus nerve-> bilateral VFP• Congenital cardiovascular anomalies

– pressure on the recurrent laryngeal nerve resulting in a unilateral vocal fold paralysis.

• Trauma to the recurrent laryngeal nerve from a traumatic childbirth delivery or from surgery leads to vocal fold paralysis that may return with time.

Vocal fold paralysis

• Presentation– Stridor– Weak cry– Recurrent aspiration

• Treatment– Time– Collagen injection– tracheostomy– Thyroplasty– Nerve reinnervation

Recurrent laryngeal nerve reinnervation

• For children with vocal fold paresis > 18 months– May be from PDA

ligation or cardiac surgery

• Dysphonia• Dysphagia/aspiration• Does not make the nerve

move but gives bulk and tone which improves voice quality

Vocal Fold Granuloma

• Often have a history of recent intubation.

• May have stridor or hoarsness

Laryngeal Granuloma

Hoarseness

• Vocal Fold Nodules• Often from vocal abuse• Treatment: Speech therapy, antacids, rarely surgery

Hoarseness- Papillomas

HPV

Maternal transmisison

Can be seen with C-sections

Cervical Lymphadenopathy

• Hundreds of lymph nodes in the head and neck

• 38-45% of healthy children have palpable cervical lymph nodes

• LAN defined as >1cm• The majority in children

are benign, self-limited inflammatory processes

Concerned Parents

• Is this cancer?• Many report family

histories of cancer which heightens their concerns

• Some have received reassurance from PMD but are still concerned.

• Some have sought multiple subspecialty consultations

Etiology of Cervical LAN

• Most common cause is reactive hyperplasia– From infectious process– Most commonly viral URI

• Chronic posterior triangle lymphadenitis may the sole presentation of acquired toxoplasmosis

• Malignant tumors– 25% of pediatric tumors occur in the head and neck– < 6yo, neuroblastoma and leukemia are the most

common followed by rhabdomyosarcoma and non-Hodgkin’s lymphoma

– >6yo: Hodgkin’s lymphoma > non-Hodgkin’s lymphoma and rhabdomyosarcoma

Etiology- Viral

• URI• EBV• CMV• Rubella• Rubeola• VZV• HSV• Coxsackievirus• HIV

Etiology- Bacterial

• Staphylococcus aureus• Group A β-hemolytic streptococci• Anaerobes• Diphtheria• Cat-scratch disease• Tuberculosis

• Protozoa- Toxoplasmosis

Malignancies

• Neuroblastoma

• Leukemia

• Lymphoma

• Rhabdomyosarcoma

Influential Clinical Factors for LAN

• History of prior malignancy• Lymph node size, > 2-3 cm• Fluctuating size• Organomegaly (liver, spleen) are sometimes associated

with malignancy• Duration of LAN is not correlated with serious pathology• Consistency of LN is not helpful but fixed lesions are likely

to be malignant• Persistent fevers and weight loss may predict a serious

pathology• Supraclavicular LNs should have a high index of suspicion.

Up to 35% can be lymphoma

Laboratory Evaluation• Not necessary in the majority of children but should be

considered in some clinical situations• CBC

– Leukocytosis and left shift- bacterial– Atypical lymphocytes- mono– Pancytopenia or blast cells- leukemia

• Serologic titer tests– Bartonella– EBV- heterophile antibody test for mono has a high false

negative rate in young children– CMV– Toxo

• LDH- marker of cell turnover which can be high in malignancy• PPD

Ultrasound

• Many studies have attempted to correlate nodal architecture, hilar shape and vascularity with cancer predictions

• Blurred nodal margins and formation of a nodal mass are found in both lymphoma and infection

• Round shape is found in 9% of reactive LNs and 78% of lymphomas

• Narrow or absent hilum is found in 6% of reactive LNs and 100% of lymphomas

• Wide range of sensitivity and specificity. Therefore, further research is needed.

Ultrasound

Reactive LN

L/S >2

Lymphomatous LN

L/S <2

FNA

• High specificity (92-100%)• Variable sensitivity- as low

as 67%• Findings correlate with the

skill and experience of the cytopathologist

• FNA is very useful if there is a positive diagnosis

• FNA can not adequately exclude serious pathology

• Some kids require sedation

Jugulodigastric Lymph Nodes

• Commonly enlarged in children

• >1.5 cm is considered lymphadenopathy

• Enlarge from URIs and pharyngitis

• Make sure it is not tonsillar hypertrophy you are palpating

Supraclavicular Lymph Nodes

• Always refer for biopsy no matter what the size is

• High likelihood of being malignant with 1/3 being lymphoma

General Management Principles

• Most cases of LAN are self-limited• Failure to regress after 4-6 weeks (with antibiotics) may

require diagnostic biopsy• Large persistent lymph nodes (>2cm) should be

biopsied• ALL supraclavicular lymph nodes should be biopsied• FNA is only useful if the findings are positive• Excisional biopsy is the diagnostic gold standard

Rosai-Dorfman disease

• Sinus histiocytosis• Massive, painless

cervical LAN• Usually presents in the

first decade of life• Need a biopsy for

confirmation• Most cases are self

limiting

Kikuchi-Fujimoto disease

• Necrotizing lymphadenitis• Benign • More common in

Japanese• F>M• Associated S&S: Fever,

nausea, weight loss, night sweats, arthralgia, and hepatoplenomegaly

• Diagnosis: Biopsy• Usually self limiting

Atypical mycobacterial lymphadenitis• Submandibular LNs most

commonly involved• M avium-intracellulare and M

scrofulaceum• Discoloration of skin

occasionally with sinus tract• CXR and PPD

recommended• Treatment: Surgical excision,

curettage +/- antibiotics• Some regress spontaneously

Post auricular dermoids and cysts

Postauricular Lymph Nodes

• Drainage basin from scalp, ear and temporoparietal areas.

• Examine for infections or breaks in the skin

QUESTIONS

• Call Center 734-936-9816

• Email davidjb@umich.edu