Evaluation and management of neck masses in children.

Neck masses in children usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic. Common congenital developmental masses in the neck include thyroglossal duct cysts, branchial cleft cysts, dermoid cysts, vascular malformations, and hemangiomas. Inflammatory neck masses can be the result of reactive lymphadenopathy, infectious lymphadenitis (viral, staphylococcal, and mycobacterial infections; cat-scratch disease), or Kawasaki disease. Common benign neoplastic lesions include pilomatrixomas, lipomas, fibromas, neurofibromas, and salivary gland tumors. Although rare in children, malignant lesions occurring in the neck include lymphoma, rhabdomyosarcoma, thyroid carcinoma, and metastatic nasopharyngeal carcinoma. Workup for a neck mass may include a complete blood count; purified protein derivative test for tuberculosis; and measurement of titers for Epstein-Barr virus, cat-scratch disease, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis if the history raises suspicion for any of these conditions. Ultrasonography is the preferred imaging study for a developmental or palpable mass. Computed tomography with intravenous contrast media is recommended for evaluating a malignancy or a suspected retropharyngeal or deep neck abscess. Congenital neck masses are excised to prevent potential growth and secondary infection of the lesion. Antibiotic therapy for suspected bacterial lymphadenitis should target Staphylococcus aureus and group A streptococcus. Lack of response to initial antibiotics should prompt consideration of intravenous antibiotic therapy, referral for possible incision and drainage, or further workup. If malignancy is suspected (accompanying type B symptoms; hard, firm, or rubbery consistency; fixed mass; supraclavicular mass; lymph node larger than 2 cm in diameter; persistent enlargement for more than two weeks; no decrease in size after four to six weeks; absence of inflammation; ulceration; failure to respond to antibiotic therapy; or a thyroid mass), the patient should be referred to a head and neck surgeon for urgent evaluation and possible biopsy.

A review of esophageal disc battery ingestions and a protocol for management.

OBJECTIVE: To review our experience with esophageal disc battery requiring endoscopic retrieval and describe a protocol for management. DESIGN: Retrospective medical chart review. PATIENTS: Pediatric patients who underwent endoscopic retrieval of an esophageal disc battery over a 10-year period. RESULTS: Ten pediatric patients had ingested an esophageal disc battery that required endoscopic removal. Three patients had minimal esophageal damage; the other 7 sustained severe and extensive esophageal damage involving the muscularis (n = 5) or developed a perforation (n = 2). One of these patients had an extensive injury that extended into the trachea resulting in a tracheoesophageal fistula. Two case reports are presented, outlining the management approach to esophageal perforations from esophageal battery ingestion. CONCLUSIONS: Severe injury can occur rapidly following disc battery ingestion. A high index of suspicion for an esophageal disc battery is necessary to expeditiously diagnose this condition. Emergency endoscopic removal is necessary. We outline a protocol for the management of this hazardous problem.

The role of intraoperative auditory brainstem response testing for infants and difficult-to-test children.

OBJECTIVE: To assess the validity of intraoperative auditory brainstem response in infants and difficult-to-treat older children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-level children's hospital. SUBJECTS AND METHODS: Twenty-six patients were identified (mean age, 20 +/- 18 months) who underwent both intraoperative auditory brainstem response (ioABR) testing and a follow-up hearing evaluation at five (standard deviation 4) months. Ears were analyzed separately for mean threshold change, and a sub-analysis was performed accounting for the presence or absence of fluid at the time of surgery. RESULTS: A paired t test analysis indicated a statistically significant difference at 1 kHz. There was not a statistically significant difference between the two groups with click or 4-kHz testing. Fifteen ears (58%) at 1 kHz and 17 ears (49%) at 4 kHz frequencies, however, improved by 10 dB or more; 67 percent and 65 percent of these ears, respectively, had middle ear fluid intraoperatively. Eight ears (35%) in the click ABR group had a similar improvement, four of which had fluid at the time of surgery. Four ears in the 1-kHz (11.5%), in the 4-kHz (11.4%), and in the click ABR group (17.4%) demonstrated a 10-dB or worse threshold. The range of the discrepancy varied from a worsening in thresholds up to 20 dB and improvement in thresholds up to 45 dB. CONCLUSIONS: We observed a significant discrepancy between ioABR and follow-up hearing thresholds. If ioABR indicates a hearing loss, audiologic testing should be performed at least several weeks later to confirm the results.

Inflammatory myofibroblastic tumor in the airway of a child.

This report describes a 9-year-old boy who was found to have an inflammatory myofibroblastic tumor completely occluding the right mainstem bronchus. Initial subtotal resection at an outside facility resulted in prompt recurrence of the tumor. At our institution, total resection with bronchotomy and pericardial patch repair resulted in an excellent outcome with no evidence of recurrence at 1 year post-resection.

Steroid treatment of hearing loss in enlarged vestibular aqueduct anomaly.

OBJECTIVE: 1. Determine whether corticosteroid therapy improves hearing thresholds of patients with enlarged vestibular aqueduct (EVA) anomaly. 2. Determine sample size for a future prospective study. METHODS: Retrospective chart review hearing loss in EVA patients comparing patients treated with corticosteroids and untreated patients. RESULTS: Eighty percent (n=5) of patients treated with steroids for hearing loss demonstrated audiometric improvement, compared to 14.3% of patients (n=7) not treated. The pure tone average improved by 17.7dB in the steroid treated group. A prospective, placebo-controlled trial would need between 19 and 45 patients in each group, treatment versus no-treatment, to achieve statistical significance. CONCLUSION: Patients with EVA who develop hearing loss have a high rate of hearing improvement when treated with corticosteroid therapy. The hearing improvement appears to be better than spontaneous recovery.