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Core > Pediatrics: Head and Neck > Flashcards

Pediatrics: Head and Neck Flashcards

1
Q

What bone makes up the nasal septum at the level of the maxillary spines?

A

Vomer

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2
Q

Pyriform aperture

A

The osseous entrance to the nasal cavity (between the maxillary spines)

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3
Q

Posterior choanae

A

The osseous exit of the nasal cavity in the back (the posterior version of the pyriform aperture)

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4
Q

Narrowing of the anterior nasal cavity at the level of the maxillary spines…

A

Pyriform aperture stenosis

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5
Q

Pyriform aperture stenosis is associated with…

A
  • Holoprosencephaly
  • Pituitary dysfunction
  • Central Megaincisor (75% of cases)

Note: All of these reflect a midline developmental problem, so hypothalamic-pituitary-adrenal axis dysfunction is common.

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6
Q

What should you recommend if you see pyriform aperture stenosis?

A

Brain MRI to look for other midline defects (e.g. holoprosencephaly, etc.)

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7
Q

Narrowing of the nasal cavity posteriorly that separates the nasal cavity from the oral cavity…

A

Choanal atresia

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8
Q

Cyclical cyanosis in an infant, respiratory distress during feeding that improves with crying…

A

Think bilateral choanal atresia (the infant can’t breath through the nose, but crying forces breathing through the mouth)

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9
Q

Can’t pass an NG tube…

A

Think choanal atresia (nasal cavity is not connected to the oral cavity)

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10
Q

Choanal atresia is associated with…

A

CHARGE

  • Coloboma
  • Heart defect
  • Atresia (choanal)
  • Retarded growth
  • Genitourinary abnormalities
  • Ear anomalies

Note: Can also be seen with Crouzons, DiGeorge, Treacher Collins, and Fetal Alcohol Syndrome.

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11
Q
A

Pyriform aperture stenosis with a singe central megaincisor

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12
Q

Respiratory distress

A

Bilateral choanal atresia with soft tissue occluding both nasal passages

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13
Q

Why are congenital deformities common in the superior nasal region?

A

There is a dural tract during embryological development that exits in the superior nasal region. Normally this closes and regresses, but can lead to defects if this doesn’t occur properly

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14
Q

Midline cystic structure in the prenasal region that does not change size during crying or jugular venous compression…

A

Think dermoid/epidermoid cyst

Note: These are often associated with a sinus tract.

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15
Q

A prenasal dural diverticulum with communication to the intracranial space would require communication through the…

A

Foramen cecum (which normally closes during development)

Note: The foramen cecum is within the frontoethmoidal suture (anterior to the cribriform plate).

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16
Q

Nasal glioma

A

Refers to ectopic brain tissue in the prenasal region due to herniation of brain tissue through the foramen cecum prior to its closing

Note: This is NOT actually a glioma, but just ectopic brain tissue.

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17
Q

Nonenhancing midline soft tissue mass in the prenasal region that grows slowly over time, but does not change size when crying or jugular compression…

A

Think nasal glioma (ectopic brain tissue in the prenasal region)

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18
Q

Midline soft tissue mass in the prenasal region of an infant that gets larger while the infant is crying (or during jugular compression)…

A

Think encephalocele (brain herniation through an unclosed foramen cecum into the prenasal region)

Note: DO NOT biopsy this, which could cause CSF leaking and meningitis.

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19
Q

Prenasal encephaloceles are associated with…

A

Other midline defects (e.g. facial clefts, callosal issues, inter hemispheric lipomas, etc.)

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20
Q

Nasal catheter is laterally displaces as it traverses the nasal cavity…

A

Look for an encephalocele (brain herniation through an unclosed foramen cecum)

Note: If the nasal catheter was displaces medially, then you would think dacryocystocele.

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21
Q

Dacryocystocele

A

Cystic structure along the medial orbital wall due to obstruction of the nasolacrimal duct. Often presents after they get infected (dacryocystitis)

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22
Q

Inflamed cyst along the medial orbital wall…

A

Dacryocystitis (infected dacryocystocele, which forms due to an obstructed nasolacrimal duct)

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23
Q

What is the most common cause of neonatal nasal obstruction?

A

Choanal atresia (followed by dacryocystocele)

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24
Q

What are the major craniofacial syndromes?

A
  • Crouzons
  • Aperts
  • Treacher collins syndromes (mandible-facial dysostosis)
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25
Q

Mandibular hypoplasia, small/absent zygomatic arches, and narrow protruding maxilla…

A

Treacher collins syndrome (mandible-facial dysostosis)

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26
Q

Narrowed mandible with inward curving of the horizontal mandibular rami…

A

Treacher Collins syndrome (mandible-facial dysostosis)

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27
Q

Where is the embryological defect that results in Treacher Collins syndrome?

A

The 1st and 2nd branchial arches

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28
Q

What is the best imaging study to look for ectopic thyroid tissue?

A

Nuclear imaging with I-123 or Tc-MIBI

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29
Q

Where are you most likely to find ectopic thyroid tissue?

A

Along the thyroglossal duct, from the base of the tongue (foramen cecum) along the midline down to behind the sternum

30
Q

What should be done before surgically removing a midline neck mass?

A

Thyroid ultrasound, to ensure that the pt has normal thyroid tissue

Note: If that neck mass represents the pts only thyroid tissue and you remove it, they will have to take levothyroxine for life.

31
Q

What is the most common location for ectopic thyroid tissue?

A

Base of the tongue (lingual thyroid)

32
Q

Midline cyst anterior to the hyoid bone…

A

Think thyroglossal duct cyst

33
Q

Midline cyst at the base of the tongue…

A

Think thyroglossal duct cyst

34
Q

Next step if you identify a midline cyst anterior to the hyoid…

A

Thyroid ultrasound to look for normal thyroid tissue +/- I-123 or Tc-MIBI study to look for ectopic thyroid tissue

Note: This is a thyroglossal duct cyst.

35
Q

Enhancing nodule within a thyroglossal duct cyst…

A

Think cancer (usually papillary)

36
Q

Thyroglossal duct cyst with rim enhancement and surrounding fat stranding…

A

Infected thyroglossal duct cyst

37
Q

Treatment for a thyroglossal duct cyst

A

Sistrunk procedure (removal of the cyst, thyroglossal duct tract, and hyoid bone (to reduce recurrence)

38
Q

Midline sublingual/submandibular cystic structure that looks like a sac of marbles…

A

Dermoid cyst

Note: Dermoid are rare above the clavicles, but when present they have the classic appearance of a sublingual sac of marbles (lobule of fat within fluid).

39
Q

What is the most common branchial cleft cyst?

A

2nd branchial cleft cyst (most often at the angle of the mandible)

40
Q

Large, cystic structure located at the angle of the mandible…

A

2nd branchial cleft cysts

41
Q

Neck cyst with extension of the cyst between the ICA and ECA…

A

2nd branchial cleft cyst

Note: Extension between the ICA and ECA is pathognomonic.

42
Q

Cystic structure lateral to the carotid space and posterolateral to the submandibular gland…

A

2nd branchial cleft cyst

Note: These tend to be lateral to pretty much everything other than skin.

43
Q

Cystic structure at the angle of the mandible that is new since 3 months prior…

A

Think necrotic lymph node (recommend biopsy and look for primary cancer)

Note: If you think something could be a branchial cleft cyst, but it recently appeared, then think necrotic lymph node.

44
Q

Lemierre’s syndrome

A

Septic thrombophelbitis secondary to a recent laryngeal infection or recent ENT surgery

Note: Can also have septic emboli to the lungs.

45
Q

Next step: Multiple cavitary nodules on chest CT with history of recent ENT procedure…

A

Neck ultrasound to look for jugular thrombophlebitis (Lemierre’s syndrome)

46
Q

Next step: Jugular vein thrombus with inflammation in a pt with history of recent pharyngeal infection…

A

Chest CT to look for septic emboli (this is septic thrombophlebitis in Lemierre’s syndrome)

47
Q

What is the bacteria that causes septic emboli in Lemierre’s syndrome?

A

Fusobacterium necrophorum

48
Q

Massively dilated jugular vein that worsens with Valsalva with no apparent cause (e.g. no stenosis or other venous congestion)…

A

Phlebectasia (idiopathic dilated jugular vein)

49
Q

Large, trans-spatial multi-cystic mass in the neck with fluid-fluid levels…

A

Think lymphatic or vascular malformation

Note: Look for enhancement of the cystic spaces (vascular malformation) or enhancement of the septa (lymphatic malformation) or phleboliths (vascular).

50
Q

How can you differentiate lymphatic and venous malformations in the neck?

A

Phleboliths or enhancement of the cystic spaces suggests vascular malformation

Enhancement of the septa suggests lymphatic malformation

Note: Both appear as large, multi-cystic neck masses.

51
Q

What is the most common congenital lesion in the head and neck?

A

Hemangioma of infancy

52
Q

When do hemangiomas of infancy usually appear?

A

Usually appear around 6 months of age, grow for a bit, and then involute by 6-10 years

53
Q

Classic appearance of hemangiomas of infancy on imaging

A
  • Super T2 bright with a bunch of flow voids
  • Diffusely vascular on Doppler ultrasound
54
Q

Indications for treatment of hemangioma of infancy

A

Large size or rapid growth that causes mass effect on important structures (e.g. airway, vascular structures, extraoccular muscles, etc.)

55
Q

Treatment for hemangioma of infancy

A

Beta blockers (propranolol), if causing mass effect on important structures

56
Q

Multiple hemangiomas of infancy (possibly involving the intra-cranial compartment) are associated with…

A

PHACES syndrome

57
Q

w can you differentiate hemangiomas of infancy from congenital hemangiomas?

A

Congenital hemangiomas are present at birth and may or may not involute (hemangiomas of infancy don’t usually appear until about 6 months and almost always involute over time)

58
Q

Obstetric ultrasound demonstrates a cystic mass hanging off the back of the neck of the fetus…

A

Think cystic hygroma (lymphangioma)

59
Q

Cystic hygromas are associated with…

A
  • Turners syndrome (most common)
  • Downs syndrome (second most common)
  • Aortic coarctation
  • Fetal hydrops (bad prognosis)

Note: The Turners baby can’t turn their head.

60
Q

If you see septations within a cystic hygroma (lymphangioma)…

A

These are associated with a worse outcome

61
Q

How can you differentiate a cystic hygroma from a hemangioma on imaging?

A

Both ate T2 bright, but only hemangiomas enhance (cystic hygromas do not enhance)

62
Q

Neonate presents with torticollis and you find a mass on the sternocleidomastoid…

A

Think fibromatosis Coli (congenital torticollis) due to benign mass-like inflammation of the sternocleidomastoid making it look very large

63
Q

Best imaging test for a neonate with torticollis…

A

Ultrasound off the sternocleidomastoid muscle (to look for fibromatosis coli)

64
Q

Treatment for fibromatosis coli

A
  • Passive physical therapy
  • Botox
65
Q

What is the most common cause of a neck mass in infancy?

A

Fibromatosis coli (mass-like inflammation of the sternocleidomastoid)

66
Q

Best imaging test for fibromatosis coli

A

Ultrasound of the sternocleidomastoid

67
Q

You suspect fibromatosis coli; what characteristics should make you think something more serious?

A

If the mass appears outside the sternocleidomastoid muscle and has internal calcifications (then think neuroblastoma)

68
Q

What is the most common mass in the masticator space of a kid?

A

Rhabdomyosarcoma (~70% occur before age 12)

69
Q

What is the most common extra-ocular orbital malignancy in children?

A

Rhabdomyosarcoma

70
Q

8 y/o with painless proptosis and no sign of infection…

A

Think rhabdomyosarcoma

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