Head and Neck Anatomy Flashcards
A 4-year-old boy is seen following a pitbull bite to his face. The periorbital findings are shown in the photograph. A stent is placed and the ends of the stent are advanced across the canaliculus. The ends of the stent will enter the nasal cavity in which of the following locations?
A) Above the superior turbinate
B) Below the superior turbinate
C) Above the middle turbinate
D) Below the middle turbinate
E) Above the inferior turbinate
F) Below the inferior turbinate
The correct response is Option F.
Reconstruction of the lacrimal apparatus is a critical step in addressing this patient’s periorbital wounds. Failure to properly manage this aspect of the injury will lead to epiphora and the inevitable need for a secondary procedure to manage tear drainage. Delayed reconstruction of this injury would likely require a conjunctivodacryocystorhinostomy, a surgically created conduit between the eyelid and the nose. The best initial management of this lacrimal apparatus disruption is as described—placement of a stent through the canaliculi, into the lacrimal duct (contained within the maxillary bone), and into the nose. The exit point of the nasolacrimal duct is via the valve of Hasner, below the inferior turbinate. It is here that the ends of the stent can be identified and retrieved, although this is often quite challenging.
The frontal, maxillary, and anterior ethmoid sinus cells drain into the middle meatus, just below the middle turbinate. The sphenoid sinus and posterior ethmoid sinuses drain into the sphenoethmoid recess, between the nasal septum and the superior turbinate.
References
Netter, F. H. Atlas of Human Anatomy. Lacrimal apparatus. Ciba-Geigy. 1989.
Drake, R., Vogl, W., Mitchell. A.W.M., Tibbitts, R. and Richardson, P. Gray’s Atlas of Anatomy. 3rd. Edition. Churchill Livingstone. 2021.
The stylopharyngeus muscle is innervated by which of the following nerves?
A) Facial (VII)
B) Glossopharyngeal (IX)
C) Hypoglossal (XII)
D) Trigeminal (V)
E) Vagus (X)
The correct response is Option B.
The pharyngeal muscles are all innervated by the vagus (X) nerve, except the stylopharyngeus muscle, which is innervated by the glossopharyngeal nerve (IX).
The trigeminal nerve (V) is responsible for facial and oral sensation. The maxillary branch (V2) is responsible for sensation of the upper teeth, upper lip, hard palate, cheeks, and nasopharyngeal mucosa. The mandibular branch (V2) provides sensory fibers for the lower teeth, lower mucosa of the mouth and the anterior two-thirds of the tongue. The facial nerve (VII) provides motor innervation of the muscles of facial expression and the posterior bellies of the stylohyoid and digastric muscles. The vagus nerve (X) provides motor innervation to all of the pharyngeal muscles except the stylopharyngeus muscle. The hypoglossal nerve (XII) provides motor innervation to the intrinsic and extrinsic tongue muscles and also provides motor innervation to the geniohyoid muscle through the ansa cervicalis.
References
Costa MMB. Neural control of swallowing. Arq Gastroenterol. 2018 Nov;55 Suppl 1(Suppl 1):61-75.
Netter FM. Glossopharyngeal nerve: schema [print]. In: Netter FM. Atlas of Human Anatomy. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010:plate 119.
During embryological development, which of the following structures is derived from the same pharyngeal arch as the antihelix?
A) Mandible
B) Maxilla
C) Mylohyoid
D) Stapes
E) Tensor veli palatini
The correct response is Option D.
The pharyngeal arches are created during embryological development by the migration of the neural crest cells and the surrounding pharyngeal endoderm and mesoderm. The first four pharyngeal arches are the most prominent and have unique nervous, arterial, muscular, and bony components. The muscular components of the first pharyngeal arch are innervated by the trigeminal nerve (cranial nerve V) and include the muscles of mastication, as well as the anterior digastric, mylohyoid, tensor tympani, and tensor veli palatini. The maxillary artery supplies blood to the components of the first pharyngeal arch. The greater wing of the sphenoid, as well as the incus, the malleus, maxilla, zygomatic, mandible, and temporal bones comprise the bony components of the first pharyngeal arch. The second pharyngeal arch is innervated by the facial nerve (cranial nerve VII) and receives blood supply from the stapedial artery. The bony components of the second pharyngeal arch include the stapes, styloid process, stylohyoid ligament, lesser horn, and upper body of the hyoid. The muscular components of the second pharyngeal arch include the muscles of facial expression, as well as the posterior digastric, stylohyoid, and stapedius.
During embryological development of the external ear, the antihelix, antitragus, and lobule are derived from the three posterior hillocks of the second pharyngeal arch, while the tragus, the root of the helix, and the superior helix are derived from the three anterior hillocks of the first pharyngeal arch.
References
Afshar M, Brugmann SA, Helms JA. Embryology of the craniofacial complex. In Rodriguez ED, Losee JE, Neligan PC, eds. Craniofacial, Head and Neck Surgery, and Pediatric Plastic Surgery. 3rd ed. London: Elsevier Saunders, 2013. Plastic Surgery; vol 3.
Sadler TW. Langman’s Medical Embryology. Baltimore, MD: Lippincott Williams & Wilkins; 2012.
A newborn has a pretragal cystic mass with a sinus tract visible in the external auditory meatus. Which of the following is the most likely diagnosis?
A) Dermoid cyst
B) First branchial cleft cyst
C) Second branchial cleft cyst
D) Third branchial cleft cyst
E) Vascular cystic lesion
The correct response is Option B.
The first branchial cleft develops into the external auditory canal. The second, third, and fourth branchial clefts merge to form the sinus of His, which will normally become involuted. When a branchial cleft is not properly involuted, a branchial cleft cyst forms. Occasionally, both the branchial pouch and branchial cleft fail to become involuted, and a complete fistula forms between the pharynx and skin.
First branchial cleft cysts are divided into type I and type II. Type I cysts are located near the external auditory canal. Most commonly, they are inferior and posterior to the tragus (base of the ear), but they may also be in the parotid gland. Type II cysts appear at the angle of the mandible and may involve the submandibular gland.
The second branchial cleft accounts for 95% of branchial anomalies, and they are most frequently identified along the anterior border of the upper third of the sternocleidomastoid muscle and adjacent to the muscle. However, these cysts may present anywhere along the course of a second branchial fistula, which proceeds from the skin of the lateral neck, between the internal and external carotid arteries, and into the palatine tonsil. Therefore, a second branchial cleft cyst is part of the differential diagnosis of a parapharyngeal mass.
Third branchial cleft cysts are rare. A third branchial fistula extends from the same skin location as a second branchial fistula (recall that the clefts merge during development); however, a third branchial fistula courses posterior to the carotid arteries and pierces the thyrohyoid membrane to enter the larynx, terminating on the lateral aspect of the pyriform sinus. Third branchial cleft cysts occur anywhere along that course (eg, inside the larynx), but they are characteristically located deep to the sternocleidomastoid muscle.
Congenital dermoid cysts of the face typically occur at the lateral orbit overlying the ZF suture, and vascular cyst lesions can be located anywhere on the face but do not present with sinus tracts into the EAC.
References
Fastenberg J, Nassar M. First Branchial Cleft Cyst. N Engl J Med. October 2016; 375:e33.
D’Souza AR, Uppal HS, De R, Zeitoun H. Updating concepts of first branchial cleft defects: a literature review. Int J Pediatr Otorhinolaryngol. 2002 Feb 1;62(2):103-9.
A newborn female presents with a large intraoral mass arising from alveolar mucosa of the lower jaw that does not cause any airway obstruction. Photographs are shown. Which of the following is the most likely pathology of the lesion?
A) Congenital epulis
B) Hemangiopericytoma
C) Odontogenic keratocyst
D) Rhabdomyosarcoma
E) Teratoma
The correct response is A.
Congenital epulis is a rare, benign tumor of the oral cavity that is found in newborns. They are considered a form of granular cell tumor that can lead to mechanical obstruction, resulting in respiratory distress or difficulty eating. Surgical excision is the treatment of choice and recurrence after excision is rare. The female-to-male ratio is 10:1. It is observed three times more frequently on the maxilla than the mandible. They are solitary in most cases, but can be large and multiple.
Teratomas and rhabdomyosarcomas of the mandible are even more rare and are usually seen in the older patient population; they are not seen in the neonatal population.
Hemangiopericytomas are rare, vascular neoplasms that originate from vascular pericytes. They can occur anywhere in the body, including the mandible. They are slow-growing and present in the older patient population. The likelihood of presentation in a neonate is exceedingly low.
Odontogenic keratocysts are rare and benign, but locally aggressive lesions of the posterior mandible. They most commonly present in the third decade of life. They make up 19% of jaw cysts.
References
Goldblum JR, Folpe AL, Weiss SW, eds. Enzinger and Weiss’s Soft Tissue Tumors. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:845.
Husain AN, Stocker JT, Dehner LP, eds. Stocker and Dehner’s Pediatric Pathology. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:1027.
The inferior oblique muscle of the orbit is innervated by which of the following cranial nerves?
A) Oculomotor (III)
B) Trochlear (IV)
C) Trigeminal (V)
D) Abducens (VI)
E) Facial (VII)
The correct response is Option A.
The inferior oblique muscle receives its nerve supply from the oculomotor nerve, or cranial nerve III. The other voluntary muscles within the orbit that receive their innervation from the oculomotor nerve are the levator palpebrae superioris, superior rectus, medial rectus, and inferior medial rectus muscles. The superior oblique muscle is innervated by the trochlear nerve (cranial nerve IV). The lateral rectus muscle is innervated by the abducens nerve (cranial nerve VI).
The inferior oblique is the only one of these muscles that does not arise from the apex of the orbit. It originates from the medial floor of the orbit just posterior to the infraorbital rim. It runs laterally, posteriorly, and upward, crossing inferior to the inferior rectus, and inserting on the posterior half of the globe beneath the lateral rectus insertion. Its action is to elevate the globe, producing upward gaze of the pupil. Risk of iatrogenic injury to the inferior oblique is greatest with transconjunctival surgical approach to the orbit. Therefore, with this procedure, care must be exercised to place the periosteal incision along the anterior aspect of the infraorbital rim.
References
Hollinshead WH. The Head and Neck. 3rd ed. Philadelphia, PA: Harper & Row Publishers; 1982:124-132. Anatomy for Surgeons; vol 1.
Turvey TA, Golden BA. Orbital anatomy for the surgeon. Oral Maxillofac Surg Clin North Am. 2012;24(4):525-36.
A 9-year-old boy is brought to the office for evaluation of a nodule on the neck that appeared 1 week ago. The nodule measures 2 cm and is slightly to the right of midline. A photograph is shown. The lesion is slightly tender. Which of the following is the most appropriate management of this lesion?
A) Excision of lesion with any tract and a section of hyoid bone
B) Excision of lesion with any tract and a section of thyroid cartilage
C) Excision of lesion with any tract only
D) Fine-needle aspiration with cytology
E) Intralesional sclerotherapy under image guidance
The correct response is Option A.
Thyroglossal duct cysts are neck lesions that usually present during childhood, often after a localized inflammation or infection. They are usually neck lesions near the midline. Some may move with swallowing if they are close to the base of the tongue, but not all exhibit this finding. The congenital thyroglossal duct is the remnant of the descent of the developing thyroid gland, and it runs from the foramen cecum of the base of the tongue, down to the thyroid. Imaging is typically by ultrasound, but other modalities, including radioisotope scans to rule out ectopic thyroid tissue or confirm the location of the normal thyroid gland, have been suggested to avoid excising ectopic thyroid gland.
The Sistrunk procedure shows less recurrence and is a complete excision, including any associated tract, and about a 1-cm section of hyoid bone. Although proposed in 1928, this is still the most commonly recommended approach for thyroglossal duct cysts.
Fine-needle aspiration is appropriate for thyroid nodules, which are unlikely to present in an acute manner in this population.
Sclerotherapy is used for vascular anomalies and likely would have presented earlier on in childhood.
References
Sistrunk WL. Technique of removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol Obstet. 1928;46:109–112.
Galluzzi F, Pignataro L, Gaini RM, et al. Risk of recurrence in children operated for thyroglossal duct cysts: A systematic review. J Pediatr Surg. 2013 Jan;48(1):222-7.
Li WY, Reinisch JF. Cysts, pits, and tumors. Plast Reconstr Surg. 2009 Jul;124(1 Suppl):106e-116e.
A 23-year-old African-American man presents with a raised thickened scar on his anterior chest that he complains is pruritic and unattractive. It was removed by another provider 4 years earlier and has slowly recurred over the past year. On examination, the lesion extends beyond the initial borders of the scar and is firm and hyper-pigmented. On review of his prior pathology report, which of the following histologic characteristics is most likely?
A) Greater ratio of type III to type I collagen
B) Multitude of myofibroblasts and smooth muscle actin
C) Parallel collagen bundles
D) Thick, wavy, and randomly oriented collagen fibers
The correct response is Option D.
In patients with abnormal or excessive scar tissue formation, treatment and prognosis will be driven by the correct diagnosis of a keloid versus a hypertrophic scar. This patient presents with a recurrent keloid of the chest. His clinical history supports this diagnosis by recurrence after resection, growth extending beyond the original border of the lesion, late recurrence after several years, and continued growth over several years without regression or improvement. Hypertrophic scars are less likely to recur, contained within the original boundaries of the lesion, often regress somewhat within a year, and recur earlier in the postoperative period if they are to recur. Both hypertrophic scars and keloid scars can be pruritic.
Pathologic analysis of keloids reveals more type I collagen than type III collagen, similar to normal skin. Hypertrophic scars will exhibit increased type III collagen and pro-fibrotic collagen cross-linking. Keloid growth is thought to be impacted by cell-signaling between keratinocytes and fibroblasts, but hypertrophic scar production requires an abundance of myofibroblasts expressing smooth muscle actin. While hypertrophic scars have parallel collagen fibrils and bundles, keloids are characterized histologically by thick, randomly oriented collagen fibrils that are not organized into bundles.
References
Arno AI, Gauglitz GG, Barret JP, et al. Up-to-date approach to manage keloids and hypertrophic scars: a useful guide. Burns. 2014 Nov;40(7):1255-1266.
Jeong HS, Lee BH, Sung HM, et al. Effect of botulinum toxin type A on differentiation of fibroblasts derived from scar tissue. Plast Reconstr Surg. 2015 Aug;136(2):171e-178e.
A 20-year-old man is brought to the emergency department after sustaining a stab wound to the neck during a violent assault. Physical examination shows an expanding neck hematoma and stridor. Intraoperative exploration shows a deep laceration to the anterior lateral neck at the level of thyroid cartilage and profuse extravasation of blood from the carotid sheath. According to anatomical zone-based classification of penetrating neck injuries, which of the following zones is involved?
A) Zone 1
B) Zone 2
C) Zone 3
D) Zone 4
The correct response is Option B.
“Penetrating neck injury represents 5-10% of all trauma cases. It is important for clinicians to be familiar with management principles, as mortality rates can be as high as 10%.”
Penetrating neck injury describes trauma to the neck that has breached the platysma muscle. The most common mechanism of injury worldwide is a stab wound from violent assault, followed by gunshot wounds, self harm, road traffic accidents, and other high velocity objects. The neck is a complex anatomical region containing important vascular, aerodigestive, and neurological structures that are relatively unprotected. Arterial injury occurs in approximately 25% of penetrating neck injuries; carotid artery involvement is seen in approximately 80% and vertebral artery in 43%.
Hard signs indicating immediate explorative surgery in penetrating neck injury:
Shock
Pulsatile bleeding or expanding hematoma
Audible bruit or palpable thrill
Airway compromise
Wound bubbling
Subcutaneous emphysema
Stridor
Hoarseness
Difficulty or pain when swallowing secretions
Neurological deficits
The assessment and management of penetrating trauma to the neck has traditionally centered on the anatomical zone-based classification first described by Monson et al. in 1969
Zone 1 extends from clavicles to cricoid, zone 2 from cricoid to angle of mandible, and zone 3 from angle of mandible to skull base.
There are only 3 zones in penetrating neck injuries.
References
Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma. 1969;9(12):987-999.
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018;100(1):6-11.
Saito N, Hito R, Burke PA, Sakai O. Imaging of penetrating injuries of the head and neck: current practice at a level I trauma center in the United States. Keio J Med. 2014;63(2):23-33.
Vishwanatha B, Sagayaraj A, Huddar SG, Kumar P, Datta RK. Penetrating neck injuries. Indian J Otolaryngol Head Neck Surg. 2007;59(3):221-224.
A 51-year-old woman is scheduled to undergo a lower lip reduction. Blockade of the mental nerve is planned for anesthesia. The most appropriate site for injection of the mental foramen blockade is the mucosa below which of the following teeth?
A) Canine
B) Central incisor
C) Lateral incisor
D) Second bicuspid
E) Second molar
The correct response is Option D.
The mental nerve foramen is located near the second bicuspid or first molar along the border of the mandible. This nerve will give sensation to the lower lip. The other answers are too distal or mesial for the mental nerve foramen.
References
Chapter 30: Face and Scalp. In: Standring S. Gray’s Anatomy. Elsevier 2018:475-506.
Scalp and Face. In: Moses KP, Banks JC, Nava PB, Petersen DK. Atlas of Clinical Gross Anatomy. Elsevier Saunders 2018(4): 26-43.
Which of the following cranial nerves develops within the first branchial arch?
A) Facial (VII)
B) Glossopharyngeal (IX)
C) Hypoglossal (XII)
D) Trigeminal (V)
E) Vagus (X)
The correct response is Option D.
The trigeminal nerve (cranial nerve V) develops from the first branchial arch and gives rise to the malleus and incus. The ligaments associated with the first branchial arch are the anterior ligament of the malleus and the sphenomandibular ligament. The muscles of the first branchial arch include the muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid), tensor veli palatini, tensor tympani, mylohyoid, and the anterior belly of the digastric. The first pouch is associated with the external auditory canal and middle ear space.
The facial nerve (cranial nerve VII) develops from the second branchial arch and gives rise to the stapes, styloid, and the upper body of the hyoid. It includes the stylohyoid ligament. The associated muscles are facial expression muscles, stapedius, stylohyoid, and the posterior belly of the digastric. The second pouch is associated with the tonsillar fossa.
The glossopharyngeal nerve (cranial nerve IX) develops from the the third branchial arch and gives rise to the lower body of the hyoid. Its muscle is the stylopharyngeus, and the pouch is associated with the inferior parathyroid gland and the thymus.
The fourth branchial arch is associated with the larynx. The muscles associated with this arch are the laryngeal, pharyngeal, and soft palate. The pouch is associated with the superior parathyroid gland and the thyroid gland.
References
Irace A, Adil E. Embryology of congenital neck masses. Operat Tech Otolaryngol Head Neck Surg. 2017;28(3):138-142.
LaRiviere CA, Waldhausen JH. Congenital cervical cysts, sinuses, and fistulae in pediatric surgery. Surg Clin North Am. 2012;92(3):583-597.
Which of the following structures contributes to the formation of the tragus?
A) First branchial arch
B) First branchial cleft
C) Second branchial arch
D) Second branchial cleft
The correct response is Option A.
The first branchial arch contributes to the formation of the tragus and anterior helix.
The first branchial cleft is incorrect. It gives rise to the external auditory canal.
The second branchial arch is incorrect. It contributes to the formation of the majority of the external ear – the antitragus, remainder of the helix, antihelix, and crura all arise from the second branchial arch.
The second branchial cleft is incorrect. It is typically obliterated during development, but may persist in the form of a second branchial cleft cyst.
References
Adams A, Mankad K, Offiah C, Childs L. Branchial Cleft Anomalies: A Pictorial Review of Embryological Development and Spectrum of Imaging Findings. Insights Imaging. 2016 Feb; 7(1): 69-76.
Schmidt R, Conrad D, Field E, O’Reilly R. Management of First Branchial Arch Anomalies via a Cartilage-Splitting Technique. Otolaryngol Head and Neck Surg. 2015 Jun;152(6):1149-51.
A 12-year-old boy with a thyroglossal duct cyst undergoes a Sistrunk procedure. Which of the following structures are resected during this procedure?
A) Cyst and cyst tract only
B) Cyst, cyst tract, and middle third of the cricothyroid cartilage
C) Cyst, cyst tract, and middle third of the hyoid bone
D) Cyst, cyst tract, and middle third of the thyroid cartilage
E) Cyst, cyst tract, and the pyramidal lobe of the thyroid
The correct response is Option C.
The Sistrunk procedure is the operation of choice for thyroglossal duct cysts. This operation involves resection of the cyst, the cyst tract, and the middle third of the hyoid bone. In the Sistrunk procedure, the thyroid cartilage is not removed, nor is the cricothyroid cartilage. If, upon exploration, the distal tract is found to be in communication with the pyramidal lobe of the thyroid, then the communication should be excised. Despite this, resection of the pyramidal lobe of the thyroid is not a standard component of the Sistrunk procedure.
References
LaRiviere CA, Waldhausen JH. Congenital cervical cysts, sinuses, and fistulae in pediatric surgery. Surg Clin North Am. 2012;92(3):583-597.
Povey HG, Selvachandran H, Peters RT, Jones MO. Management of suspected thyroglossal duct cysts. J Pediatr Surg. 2018;53(2):281-282.
Which of the following structures is formed from the same branchial arch as the vagus (X) nerve?
A) Inferior parathyroid glands
B) Lesser horn of hyoid
C) Levator veli palatini
D) Maxillary artery
E) Styloid process
The correct response is Option C.
Each of the six branchial arches gives rise to a branch of the aortic arch, a cranial nerve, muscular structures, and skeletal structures. The fourth branchial arch gives rise to the right proximal subclavian artery, the aortic arch, the vagus (X) nerve, the superior laryngeal nerve, the intrinsic muscles of the levator veli palatini, cricothyroid muscles, laryngeal cartilages, and the superior parathyroid glands.
The styloid process is derived from the second branchial arch, along with the stapedial and hyoid arteries, the facial (VII) nerve, the muscles of facial expression, the stapes, the lesser horn of the hyoid bone, and the crypts of the palatine tonsils.
The maxillary artery is derived from the first branchial arch, along with the trigeminal (V) nerve, the muscles of mastication, anterior belly of the digastric muscle, tensor tympani, tensor veli palatini, mylohyoid, mandible, incus and malleus, maxilla, vomer, zygoma, and temporal bone.
The inferior parathyroid glands are derived from the third branchial arch, along with the common carotid artery, internal carotid artery, glossopharyngeal (IX) nerve, stylopharyngeus muscle, greater horn of the hyoid bone, and thymus.
The lesser horn of the hyoid bone is derived from the second branchial arch.
References
Adams A, Mankad K, Offiah C, Childs L. Branchial Cleft Anomalies: A Pictorial Review of Embryological Development and Spectrum of Imaging Findings. Insights Imaging. 2016 Feb; 7(1):69-76.
Cohen M. Malformations of the Craniofacial Region: Evolutionary, Embryologic, Genetic, and Clinical Perspectives. Am J Med Genet A. 2002 Dec; 115(4):245-68.
A 12-month-old boy presents for evaluation of a soft, fixed lateral brow mass that has been enlarging since it was first noted at 2 months of age. A photograph is shown. The parents report that the mass does not change in size during crying or activity, nor did it change in size during recurrent pink eye infections. Which of the following is the most likely diagnosis?
A) Branchial cleft cyst
B) Dermoid cyst
C) Hemangioma
D) Lacrimal gland
E) Lymphatic malformation
The correct response is Option B.
Dermoid cyst is the correct answer and the most common cause of a lateral brow mass in an infant. If it were a hemangioma, its size would change during crying or any activity that increases blood flow. Lacrimal gland ptosis is unlikely in a child but can be seen in the adult population, and can be ruled out if the mass is above the orbital rim, as seen in the photograph. The mass is not in the distribution of any of the different types of branchial cleft cysts. Lymphatic malformations typically change in size during infections.
References
Al-Muhaylib A, Alkatan HM, Al-Faky YH, Alsuhaibani AH. Periorbital lesions misdiagnosed as dermoid cysts. J AAPOS. 2017;21(6):509-511.
Rezaei E, Shams Hojjati Y. Misdiagnosed extranasal mass: report of a 2-year old child with maltreated rare nasal neuroglial heterotopia. World J Plast Surg. 2019;8(1):122-124.
Van Wyhe RD, Chamata ES, Hollier LH. Midline craniofacial masses in children. Semin Plast Surg. 2016;30(4):176-180.
Vincent J, Baker P, Grischkan J, Fernandez Faith E. Subcutaneous midline nasal mass in an infant due to an intramuscular lipoma. Pediatr Dermatol. 2017;34(3):e135-e136.
A 2-year-old boy is evaluated because of a soft, nontender, noncompressible glabellar mass that has progressively grown since birth. A photograph is shown. Which of the following is the most appropriate next step in management before scheduling surgery?
A) Corticosteroid injections
B) MRI
C) Plain film x-ray study
D) Propranolol trial
E) Observation
The correct response is Option B.
The differential diagnosis for a lesion in this location with the findings described include dermoid cyst, hemangioma, and encephalocele. Osteoma, which is a benign bony tumor, is unlikely because of patient age and examination findings. The noncompressible quality of the lesion makes hemangioma and encephalocele less likely. Propranolol therapy after 12 months of age is unlikely to help, even if the lesion is a hemangioma. If the lesion is a hemangioma, then observation would be appropriate, but because the lesion is still growing, this diagnosis is questionable. Corticosteroid injections are only moderately helpful in treating a hemangioma, but they are contraindicated for dermoid cysts and encephalocele. Diagnosis is the next step with a goal of ruling out intracranial communication, as it will impact the surgical approach. MRI is the best option. Plain x-rays films would not provide adequate information for management.
References
Al-Muhaylib A, Alkatan HM, Al-Faky YH, Alsuhaibani AH. Periorbital lesions misdiagnosed as dermoid cysts. J AAPOS. 2017;21(6):509-511.
Rezaei E, Shams Hojjati Y. Misdiagnosed extranasal mass: report of a 2-year old child with maltreated rare nasal neuroglial heterotopia. World J Plast Surg. 2019;8(1):122-124.
Van Wyhe RD, Chamata ES, Hollier LH. Midline craniofacial masses in children. Semin Plast Surg. 2016;30(4):176-180.
Vincent J, Baker P, Grischkan J, Fernandez Faith E. Subcutaneous midline nasal mass in an infant due to an intramuscular lipoma. Pediatr Dermatol. 2017;34(3):e135-e136.
