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Clinical Pearls

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

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Clinical Pearls

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  1. Clinical Pearls Eric D. Baum, MD Connecticut Pediatric Otolaryngology Madison · North Haven · Shelton · Yale-New Haven Children’s Hospital

  2. 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 PediatrAdolesc Med, 2010.

  3. 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.

  4. Embryology and Workup Cambiaghi S, Micheli S, et al. PedDermatol, 2007.

  5. 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.

  6. Timing of Nasal Fracture Evaluation • Too soon: edema often obscures examination • Too late: closed reduction no longer possible • There is no data

  7. 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

  8. Initial Evaluation • Usual overall assessment • Other injuries • Intracranial • Physical exam • Describe nasal abnormality • Radiologic studies rarely helpful • Must rule out septal hematoma

  9. Septal Hematoma - Urgent AO Foundation Website, 2012

  10. Septal Hematoma - Exam www.entusa.com, 2012 Soma DB, Homme JH. Int J Ped ORL, 2011.

  11. 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.

  12. Auricular Hematoma • Same idea as septal hematoma • Shear forces on lateral auricle • Teenage boys • Wrestling • Boxing • Martial arts

  13. 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. FacPlasSurg, 2010.

  14. If It Works, Great Brickman K, Adams DZ, et al. Clin J Sport Med, 2012.

  15. Must Keep Fluid From Reaccumulating Kakarala K, Kieff DA, Laryngoscope, 2012. Roy S, Smith LP. Am J Otolaryngol, 2010.

  16. Delay = Cauliflower Ear

  17. Hard to Repair Fujiwara M, Suzuki A, et al. J Plast Recon AesthSurg, 2011.

  18. Cefdinirand Red Stool Mookadam M, Eisenhart A. Ann Emerg Med, 2009.

  19. 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.

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