Pediatric emergency medicine trisk 2681 2681

Clinical Recognition
Intraorbital tumors may involve any of the tissues contained by the orbit including
bone, muscle, soft tissue, and the globe itself. Masses in these regions have a wide
differential diagnosis, including infections (periorbital and orbital cellulitis), orbital
myositis, benign germ cell tumors, or cystic lesions such as a dermoid cyst.
Retinoblastoma is the most common intraocular malignancy in children. It occurs in
1 in 23,000 births and is usually diagnosed by age 2. Two-thirds of patients with
retinoblastoma present with a white pupil (leukocoria) noted by parents. This is the
tumor as seen through the vitreous. The most common malignancies affecting the
bony orbit are LCH and neuroblastoma. Presenting symptoms usually include
proptosis and strabismus. Vascular tumors including capillary hemangiomas of the
orbit may present with red or purple nodular lid lesions or proptosis.
Masses in the aerodigestive tract may be benign, infectious, or reactive in
etiology. Regardless of the tissue of origin, these masses usually present with
symptoms related to their anatomic position.
Oropharyngeal tumors such as with Burkitt lymphoma can cause snoring and
obstructive sleep apnea as well as chronic otitis media and unilateral tonsillar
hypertrophy. Gingival hypertrophy may be a sign of a monocytic leukemia. LCH or
Burkitt lymphoma of the mandible can present with loose teeth. Rhabdomyosarcoma
of the salivary or parotid gland often presents with pain or a facial mass. Malignant
tumors of the nose, nasopharynx, and sinuses can present with purulent or bloody
rhinorrhea, epistaxis, or sinusitis. Nasopharyngeal carcinoma tends to have a long
duration of symptoms before diagnosis because symptoms are rarely specific.
Malignant tumors of the sinuses and base of the skull can present with cranial
neuropathies such as deviation of the eyes due to compression of the cranial nerves
by the tumor. Rhabdomyosarcoma of the middle ear can present with persistent
otitis, pain, or cranial neuropathy. The external ear canal can be affected by LCH
leading to otorrhea and otitis externa.
Neck masses due to benign congenital anomalies such as branchial cleft cysts or
cystic hygromas may grow suddenly as a result of infection or bleeding.
Lymphadenopathy in children is common and usually benign. It is most commonly

either reactive or infectious in etiology. Bilateral nodes may be associated with viral
infections such as EBV or cytomegalovirus (CMV). Unilateral lymphadenopathy or
lymphadenitis, especially in infants and young children, may be associated with
Staphylococcus aureus or group A streptococcus infections. Even lymph node
enlargement with a chronic time course is still most likely infectious (e.g.,
mycobacteria, cat-scratch disease, toxoplasma). Lymph nodes can appear large even
without infection or malignancy, as observed in Castlemans, Kikuchis, and Rosai–
Dorfman syndromes. Enlarged lymph nodes in the neck due to malignancy can be