Pediatric emergency medicine trisk 0949 0949

pulses, systolic hypertension, exophthalmos) or deficiency. Orthopnea or
wheezing while supine may be an early sign of a mediastinal mass. Failure to
thrive or weight loss may also be associated with multiple causes of infection or
oncologic illness, including HIV disease, histiocytosis X, mycobacterial
infections, and others. Likewise, generalized lymphadenopathy in conjunction
with fever or rashes may indicate an inflammatory or oncologic process. A full
examination of the skin is therefore imperative, with special attention to any
animal scratches or bites of the face and extremities. Suspicion for malignancy
increases with changes in the general appearance and color of the child, as with
the presence of hepatosplenomegaly or an abdominal mass.

DIFFERENTIAL DIAGNOSIS
Congenital Masses
Thyroglossal duct cysts are the most common congenital cyst of the neck,
resulting from failure of embryologic thyroglossal duct obliteration prior to hyoid
bone formation. More than half are diagnosed in children younger than 10 years
of age. Although 65% of these are found to be infrahyoid, they can develop
anywhere in the anterior triangle (along the midline from the base of the tongue
to the sternal notch). These may become apparent initially after an upper
respiratory infection (URI) or an episode of hemorrhage. Masses from
thyroglossal duct cysts are classically soft, nontender, smooth, and may move
cranially when the child swallows or protrudes the tongue. When infected, they
may be warm, erythematous, and drain externally. If drainage occurs by way of
the foramen cecum, there may be an associated foul taste in the mouth.
Antibiotics (for mouth and skin flora), warm compresses, and incision and
drainage (if indicated) should be initiated for signs of infection. Complete
excision is the treatment of choice after resolution of the acute infection.
Branchial cleft anomalies most commonly occur from defects in the
development of the second branchial arch, giving rise to firm posterior triangle
masses (along the anterior border of the sternocleidomastoid muscle near the
angle of the mandible). Branchial cleft sinuses present with a pit with or without

drainage at the junction of the middle and lower thirds of the sternocleidomastoid
muscle. Blockage of the sinus tract may cause cysts which are usually fluctuant,
mobile, and nontender. Conversely, probing or injecting the tract may precipitate
an infection, causing warmth and tenderness. Consequently, incision and drainage
should be avoided because it may result in fistula formation. Ultrasonography
(US) may be useful in identifying a thin-walled, anechoic, fluid-filled cyst.