In this talk for primary care providers, pediatric otolaryngologist Grace Banik, MD, discusses how to assess and categorize the range of neck lumps that can affect children, presenting criteria on location, size, mobility and other features, as well as questions to ask when gathering a history. She describes cyst types; explains when to suspect cancer; offers workup guidance, including lab tests and imaging; and advises on when to refer. Bonus: Banik lays out steps for primary care management of other common ENT diagnoses when seeing a specialist isn’t warranted.
Um, so I don't have any disclosures for my talk today. Um, the objectives of this talk are, um, to, at the end of it, be able to describe the studies and criteria used to diagnose pediatric head and neck masses, um, and to differentiate features of, um, of various benign and malignant, um, pediatric head and neck masses, as well as understand the general medical, surgical management of them, um, and identify when and where to refer patients. So I thought I would frame this topic um in kind of the context of a few cases of, of patients that you might see um in your clinic, um, and So the first case is a 5 year old male who is coming to his well-child visit with a lump on his neck. Um, uh, mom and dad first noticed it maybe about 5 weeks ago, had a cold at the time with a runny nose and cough. Um, the cold went away, uh, a little bit of a lingering cough, but the lump has kind of stuck around. Um, otherwise healthy kid and, um, only has a positive family history for a grandmother with breast cancer and so parents are a little bit concerned. Um, that, you know, they wanna make sure that there's nothing, um, bad or dangerous going on. So when you are seeing um a patient in, in your clinic with a head and neck mass, um, these are some of the things that uh are important to ask about. Um, so, first of all, the location of it. Does it seem like it's more of a midline structure or a lateral one? Um, is it just one lump or is it multiple? When did it start? Um, and kinda how long has it been around for? Um, It's important to ask about size changes over time, so whether it has been stable, growing, or um actually getting better over time, as well as any overlying skin changes. Um, and we'll talk about that a little bit more later on in the presentation, but particularly erythema, edema, um, and drainage. Uh, and then obviously systemic symptoms, fever, night sweats, weight loss, fatigue, um, And then some other risk factors such as recent illnesses, travel, particularly international travel, um, exposure to cats, goats, or rabbits, um, and then ingestion of certain unpasteurized dairy products or undercooked meat, and then, um, uh, history of radiation exposure, particularly those patients who have had a lot of radiation for treatment of cancer, for example, um, and then a family history of cancer. So if we go back to our 5 year old um in your clinic, when you do your physical exam, you know that he has a 1 to 2 centimeter um subcutaneous kind of firmish um mobile mass that's right behind his SCM muscle. Um, there's no overlying skin changes, no tenderness when you touch it, no drainage, um, it's just kind of this lump, um. So the important things to look for on your physical exam would be again location um relative to other structures in the neck and then uh getting a sense of how big it is. Um, it's often hard to tell until you get imaging but um a general sense is helpful. Um, the consistency of the mass, so is it soft? Is it firm? Is it kind of rubbery? Is it very clearly cystic and how it fluctuates? Um, and then does it move relative to both the skin and then the underlying, um, uh, underlying tissue in the neck? Is it well circumscribed or is this, does it have kind of like an irregular border to it? Um, Does it hurt when you, when you touch it? And again, those overlying skin changes that we talked about, whether there's actually a punctum or a little, um, a little hole that you can see. Um, and then some other specific ones which would be, um, elevation with swallowing. So this is, uh, relevant for more midline structures in the neck. Um, and then do they have any other general symptoms in the head and neck, um, which would include hoarseness of their voice, uh, noisy breathing, snoring, stridor, difficulty breathing, or difficulty swallowing? So just a quick review of important neck anatomy. Um, when we think about the neck from an ENT or surgical perspective, we tend to divide it into, uh, what we call levels. Um, so there are levels 1 through, um, 1 through 6 on this diagram, um, but they go up to 7, and the are kind of bordered by anatomical structures that we see intraoperatively. Um, so they aren't necessarily the most intuitive, um, but generally, your level one of your neck is gonna be in the submental area between, uh, your digastric muscles, and then, um, your level two is a little bit lateral to that but still superior to the hyoid bone. Your level 3 is between your hyoid bone laterally um and your cricoid cartilage and level 4 is um below your cricoid cartilage down to your clavicle or sternal notch, and then level 5 is your posterior triangle, so everything posterior to your SCM muscle. Now, one of the, you know, most common questions that we We get is what is a normal lymph node or what constitutes an abnormal lymph node. Uh, conversely, there's unfortunately no universal size criteria in children at this point, um, but I would say in general in the head and the neck, we think about potentially abnormal lymph nodes. Once a lymph node. is greater than about 1 centimeter in most levels or most areas of the neck and then particularly in level 2, so kind of the superior, um, posterior aspect of the lateral neck, um, you have a little bit more leeway, so up to 1.5 centimeters is considered, uh, Pretty normal and that's, and it's important to know that that's the short axis and not the kind of uh not the superior inferior axis and not the longest um axis of that lymph node. Um, that you're using for that cutoff. And this diagram here on the right is just to indicate that, so when you look at level two lymph nodes and you just look at the kind of general gamut of lymph node sizes, there is a very large range of ones that fall into the um normal category versus um abnormal category and, uh, and then this highlights that difference between the short axis and then the long coronal axis and how different they uh really can be. All right. And then, what generally causes cervical lymphadenopathy in children? So, um, so there are a million viruses that can do it, um, that I haven't listed here, but one that we think about, um, that's a little bit on the atypical side is mononucleosis, um, that's one that's important to keep in mind. And then, Uh, there's also bacteria that can cause, um, both a reactive lymphadenopathy and then a lymphadenitis where you're having an, um, inflammation of or infection of the lymph node itself. And those bacteria are typically Staph aureus, um, and nowadays you really do need to consider MRSA, you know, for, um, for young children. And then group A streptococcus, um, and more rarely atypical mycobacteria and Bartonella. Another frequent question that we get is how long does lymphadenopathy last? Um, and in the setting of acute lymphadenopathy, less than 2 weeks generally, um, you would expect that to be almost always like a viral or bacterial reactive lymphadenopathy. Um, if it lasts longer than that, so, uh, 2 to 6 weeks, we consider that to be subacute, and those tend to be still infectious etiologies, but perhaps some of the, um, more lingering slow burn etiologies such as like atypical infections and cat scratch disease. And then when you get into, uh, chronic lymphadenopathy, that's considered over 6 weeks or so, um, and that's when you should be starting to think about less common um etiologies that are not necessarily infectious, um, such as inflammatory or neoplastic processes. Now, if we switch gears and go to a different case, um, this is a 3 year old female who is presenting now with recurrent left neck swelling. Um, the first episode was a few months ago, totally asymptomatic at the at the time and resolved on its own after a few days. Um, and then a couple of days ago, had a low-grade fever and then started to notice that she was getting swelling in pretty much the exact same spot, um, and also had a little bit of a decreased appetite. Past medical history only significant really for asthma. Um, and then this is what you see on your physical exam. So, um, there is about, you know, sort of a 4 centimeter, tender, um, fairly superficial, like you can feel, um, you can feel that it's fluid-filled right under the skin. Uh, it's at the anterior neck a little bit to the left, um, and then has some skin changes over the top with some erythema. Um, and so you get an ultrasound, um, which shows that, uh, it's a 4 centimeter nicely circumscribed cystic lesion adjacent to the superior pole of the left side of the thyroid. So if we take a step back and think about all the different things that can cause um a lump in the neck, um, Including, you know, the one that we just saw. So the most common diagnosis like we just reviewed is reactive cervical lymphadenopathy. Um, and, uh, the thing that worries everyone is, OK, so what are the odds that this is gonna be something that's not just a benign process, and I just wanted to, you know, To put out there that in a study of um patients who are specifically seen by ENT uh only 10%, 10 to 11% of those were malignant. And so if you put that in the context of all patients who are seen by primary care providers um for a lump in their neck, that's gonna be much, much, much lower. So what are some common lumps that we see in the neck, um, besides reactive lymphadenopathy and lymphadenitis, there are some inflammatory causes, so, um, a deep neck space infection such as a retropharyngeal or parapharyngeal abscess, um, atypical mycobacterial infections, um, and then there are congenital masses, so, uh, we think about brachial cleft cysts, we think about thyroglossal duct cysts and dermoid cysts, um, in patients who say that they've had it since they were born and Um, and then there's always neoplastic, um, processes in the back of everyone's mind, and the most common of that is, uh, lymphoma. Now Some of the more rare bumps that we see in the neck, um, are in the inflammatory category cellulodenitis, so parotitis or, um, more rarely submandibular inflammation. Um, and then there's other kind of viral, um, more proliferative disorders, so Kawasaki, uh, can present with some cervical lymphadenopathy, um, and then kind of Kakuchi, Fujimoto, Rosai, Dorfman, Castleman. These are Rare, um, inflammatory disorders, um, but they often present with, um, either one or multiple enlarged lymph nodes, um, tuberculosis, and, uh, and then congenitally, we, um, Also sometimes encounter something called a vascular tumor or a vascular malformation, the vascular tumor, the most common being uh hemangiomas, um, which we'll talk about a little bit more later on, and then malformations being either um venous malformations or lymphatic malformations. And then for neoplastic processes, um, they can be both benign like a pylomatrixoma, um, or a lipoma, or they can be malignant, so thyroid cancer, uh, and salivary gland tumors, neuroblastoma, and rhabdomyosarcoma. This is kind of a general breakdown of the ages at which these different categories of um lumps and bumps tend to present. This isn't, uh, this isn't the full range, but it's sort of the most common ages to really kinda help um break things down. So if someone's coming to you with um this mass that has been there since birth or they're under the age of 6, oftentimes it's a congenital issue. Um, and then between the ages of 2 and 8 are when we see the peak of, um, of children having like inflammatory lymphadenitis, lymph, uh, adenopathy, um, and then over the age of 10, always with, you know, exceptions, of course, but, um, generally over the age of 10 is when we see, uh, uh, increase in the frequency of those neoplastic issues. Um, I wanted to emphasize that when it comes to neck masses, um, location is super important, um, and can help you, help sort of guide you in the right direction of figuring out what's going on and how to manage it. Um, In the midline, there are not that many masses that present um in, you know, sort of in the center of the neck um or of the head, and those are typically either gonna be a thyroglossal duct cyst or a dermoid cyst. Lateral masses um are often, you know, brachial cleft cysts, um, or just general cervical lymphadenopathy. Um, posteriorly in that posterior triangle behind the SCM, uh, you're, you're gonna see kind of more like lymphadenopathy or lymphadenitis, um, inferiorly in the, again in like kind of the central compartment of the neck, um, you have to think about thyroid cancer. And then if it's Uh, located preauricular or submandibular, then things to think about would be atypical mycobacterial infections, um, yoatonitis because the parotid gland is gonna be pre-auricular and the submandibular gland is gonna be, um, under the jaw here, um, a tumor within those glands, um, and then HIV can, uh, sometimes present. In children actually with bilateral parotid um masses and so that's something that's important to, um to be aware of. Um, if you have a mass that's in the supraclavicular area, there's a very high uh risk that that is um actually a malignancy and, uh, either lymphoma or metastatic cancer from elsewhere. Anywhere in the head and neck area, um, you can see vascular tumors and malformations and, uh, and then if you're seeing really kind of shoddy masses, so, um, scattered all over the place, that's most commonly gonna just be some cervical lymphadenopathy, um, and less commonly lymphoma. Uh, now I wanted to talk about a few of the more common etiologies that you might see and might refer on. Um, and so the first one is atypical mycobacterial infections. These are caused by non-tuberculous mycobacteria. Um, they are kind of in the soil and water in general, um, and, uh, it presents as a painless fluctuent mass that the hallmark feature is this violacious or purple discoloration of the skin overlying it. Um, usually, it's been there for, um, For a few weeks, sometimes a few months. Um, and, uh, and, uh, a diagnostic test that we will frequently use for, um, this is a PPD. So, um, those can sometimes detect the atypical mycobacteria. Um, and they're managed with a prolonged course of antibiotics that lasts about 12 weeks and is a combination of often a macrolide plus, um, plus rifampin, um, or some other combination. Unusually, we will take them to the operating room to actually do um an excision or if we can't do an excision due to um it being unsafe in terms of the location relative to important structures like the facial nerve, um, then sometimes we'll do actually just an incision and then curettage um to help it resolve. Um, another common etiology is cat scratch disease, so that's caused by Bartonella, um, and that's located in a cat saliva most commonly. Um, it presents as either one lymph node or multiple enlarged lymph nodes that are Typically near the initial like inoculation site, so where they got scratched by a cat, for example. Um, it can develop in a delayed fashion, so weeks, months after, um, the initial scratch and so oftentimes the history is a little bit, um, is a little bit. Unclear and uh they don't necessarily remember the initial um being scratched uh incident. Um, but these are important to distinguish because they're managed purely with antibiotics but they often do need antibiotics to resolve. And then if we think about more congenital masses, so brachial cleft cysts, so these are, um, these are masses that children are born with, and they're the most common congenital, um, masses in children. Uh, they are sort of abnormal developments from the brachial clefts, um, and those are the, um, pouchings of ectoderm, um, and So there's about 4, kind of 3 to 4 brachial clefts, uh, that are gonna present in the neck and, um, and they present differently because of the, um, kind of structures that they're derived from. So the first brachial. Cleft cysts are often located higher up towards the ear canal or parotid glands or preauricular. Um, sometimes they can actually be inside the ear canal. Second brachial cleft cysts are often a little bit lower and they're kind of along the anterior border of the SCM. Um, and then 3rd, 4th brachial cleft cysts, um, some people will actually argue that there is no difference between the 3rd and 4th brachial cleft cyst, um, uh, so they often get grouped together, but in general these actually have an opening, um, in the piriform sinus, so, um, that's gonna be in the, uh, in the pharynx, in the hypopharynx next to the, um, next to the larynx, um. And the glottis and you can see if you do like a direct laryngoscopy or a scope um into their airway, you can see oftentimes like a little tiny hole that opens um into this uh brachial cleft cyst. And then the other end of it tends to be somewhere near the thyroid gland. Um, we almost always get MRI's for these masses when they come to us, um, so that we can plan for surgical excision. We avoid doing anything to them when they're acutely infected, which commonly they are, um, at presentation. Um, but eventually we signed them up to have, um, excision, uh, of both the cyst and the tract, um, once they're completely well. Um, another congenital, um, uh, neck mass is a thyroglossal duct cyst. Uh, these are, um, these are sometimes confused with dermoid cysts, um, and so we'll talk about some of the differences between the two, but for thyroglossal duct cysts, they're related to remnants, as you can see in this diagram here along the path of the thyroid descent as it's moving from the back of the tongue at the foramen cecum down to the, um, down to in front of the trachea. Um, it is always midline, um, and it's cystic. Usually somewhere near the hyoid bone, it can um be either behind it a little bit or um superior and um superficial to it. One of the telltale signs of these masses is that it elevates when you swallow or you stick your tongue out because it is tethered by this, um, by this duct. And, um, and then you would always wanna confirm the presence that there is other normal thyroid thyroid gland tissue, uh, in the normal place before proceeding with taking These out, um, because otherwise you might be removing their only functional thyroid tissue. Um, and they often become infected when they have, um, a URI and the management of it is surgical removal. Um, it's a little bit more extensive than just a simple excision, um, because there's a high rate of occurrence, um, and, uh, and so we do something called a procedure where you remove actually a central part of this hyoid bone to get rid of the entire tract, um, uh, in addition to the mass. Um, dermoid cysts present very similarly. They're actually, um, from, from kind of the sebaceous glands and hair follicles though. Um, they're midline, they're cystic, they're often near the hyoid bone. They can also present on the nasal dorsum. Um, they tend to be more attached to the skin and superficial, um, and have this like very characteristic like cheesy yellow appearance. Um, ultrasound is usually fine to diagnose these and in contrast to thyroglossal ductus, we usually just simply, um, excise them. Um, and then, and then we have vascular tumors and malformations, so again vascular tumors hemangiomas are the most common. These present either at birth if they're congenital hemangioma or shortly after, um, if they're the infantile hemangioma form, um, congenital ones tend to be completely formed and, um, at their, you know, full size when they're born and almost always involute completely by the age of 9. Um, on their own without intervention. Infantile hemangiomas will grow, um, progressively and sometimes quite rapidly until the age of about one, and then sometimes they involute, but sometimes we have to, uh, intervene with propranolol to, um, if they're, you know, if they're growing, um, in a problematic way or if they're not involuting, um, as much as or quickly as we would like. Uh, and then vascular malformations, these may or may not be present at birth. They tend to grow in proportion, um, with the patient and, uh, we'll get MRIs to characterize them and then either, um, treat it with sclerotherapy where it's injected, um, with a material that causes it to scar off or, um, surgical excision. And then pylomatrixomas, um, these are fairly common, uh, masses as well, um, they're derived from hair follicles, the, the You know, defining feature of these is that they're rock hard pebbles that are just under the skin, often in like the post auricular, posterior neck area. Um, they're, they're benign, they're generally harmless, um, sometimes can get infected, but we either, if, you know, observe them or if they're starting to cause problems, um, or bothersome, then we will, uh, excise them. And then thyroid cancer, which is um my particular area of clinical interest, um, can present in children. It's much more common in adults, but it does happen in children. Um, the vast majority of thyroid cancers in children are, um, are the papillary thyroid carcinoma, um, type. They have excellent overall survival, fortunately, greater than 99% of children, um. Uh, have long-term, um, long-term survival, um, and so it's really a disease that children once treated, just live with. Um, and, um, and then it will often present as either a nodule in the thyroid or actually with, um, more, uh, widespread disease. So, It can present with diffuse lymphadenopathy. The workup involves getting an ultrasound of the thyroid as well as the lateral neck um to check for metastasis and then, and then we'll get an FNA um or a biopsy of the, um, of the thyroid nodule to confirm the diagnosis. Sometimes we'll get molecular testing to help us with treatment. And it's managed surgically, primarily with removal of the thyroid and any involved um neck lymph nodes. Uh, and then afterwards, they will sometimes get um radioactive iodine therapy to eliminate microscopic disease. So the last case that I wanted to um to present is a 16-year-old male who um comes to your clinic with just right-sided neck swelling, and um it was first noticed about 2-3 months ago, he got hit in the head with a soccer ball and then, you know, it was just sort of was like paying a little bit close attention to his neck and noticed that there was something there. Um, it's been about stable to slightly increased in size. Um, he does endorse that, you know, he's kind of tired during the day, but he also stays up very late and he's a teenager. Um, no significant past medical history, um, or family history. And then on your physical exam, you see that he has sort of this very um generalized um non-discrete fullness at his right lateral neck. Um, there's no tenderness there, no skin changes, no drainage, and when you get an ultrasound, um, you see multiple lymph nodes that are markedly enlarged up to 4 centimeters, um, and they're sort of scattered throughout the right level 2 to 4. They have this kind of, um, This homogeneous hypoechoic like darker appearance on ultrasound and loss of their normal fatty hylum. So I wanted to, um, I wanted to parlay that into discussing the workup now of um a neck mass when it presents to you. And so, um, there's a few different things that I, I recommend ordering when you have um a neck mass of unclear etiology. Um, you can consider doing labs, um. Starting with a CBC ESR CRP really to see if this is an inflammatory process. Um, and then if there's a suspicion for atypical mycobacteria, um, on your clinical exam, then getting a PPD, um, and, and then if, you know, there's a, a suspicion that this could be either like a, um, Uh, reactive lymphadenopathy, um, or, um, other viral etiology, then getting serologies is very helpful. So CMV serologies, EBV, um, and HIV if indicated. It's important to get both the IgM and the IgG. Because, uh, a positive IgG is fairly common with CMV and EBV cause most children, um, at some point have been exposed to that. Uh, so the IGM is really important to know whether it's truly an acute infection, um, that could be causing their lymphadenopathy. And then, again, based on their history, um, you could order as well Bartonella, toxoplasmosis, and Lyme titers, um. And then, uh, if there's a concern for um lymphoma or malignancy, then LDH and uric acid. Um, and then other diagnostic testing to order which we'll talk a little bit more about our, um, various imaging modalities and then biopsying. Um, so what type of imaging to order? Um, you have the options of ultrasound, um, and then CT and MRI. I generally recommend, uh, starting with an ultrasound almost always. And the benefits of an ultrasound are that there's no radiation involved, there's no sedation involved, um, and it is excellent for superficial lesions. It's really Um, it's great for characterizing lymph nodes, um, and it can tell you a lot of information. So it tells you the size, location, shape, consistency, whether there's a normal fatty hylum and whether there's vascularity to, uh, to the mass. CT and MRI we often will, um, order when we're starting to maybe think about either deeper, um, masses and, uh, and checking for For ones that are involving the bone or if we're thinking about surgical planning. Um, The downside is that you do have to sedate oftentimes for an MRI and then also for a CT realistically, um, in most children and uh so they have to go under general anesthesia for that. Um, but they are much better at characterizing the full neck and seeing if there are any other foci, um, uh, of involvement and they're also just kind of better for getting a sense of the characteristics of, of these lesions. Um. MRI tends to be superior for soft tissue masses and differentiating between different types of soft tissues of fat versus muscle, um, and also for vascular lesions. And then biopsy. So how do we generally biopsy these, um, these things and the two main, um, least invasive ways that we do that are either fine needle aspiration or core needle biopsy. Fine needle aspiration really is the workhorse of, um, biopsying neck masses in children. It's got excellent sensitivity and specificity, 94% or more, um, sensitivity and 97% or more specificity. Um, usually, it'll be done under ultrasound guidance, um, to make sure that you're getting an adequate sample of the right, of the right part of the neck, um, unless it's really obviously palpable superficial. And UCSF actually has a same-day walk-in FNA clinic, um, that you can send your patients to that has ultrasound-guided FNA services. Um, Needle biopsies tend to use a slightly larger bore um needle to get more tissue, um, and get a little bit of the architecture of um the mass in the biopsy than fine needle aspiration which is really looking at just the cells um in sort of a wash. Um, the corneal biopsies, you can actually have like a, a little column of tissue and they have, um, as a result of that, better sensitivity and specificity that's approaching 100%. Um So when you're thinking about a patient that you are seeing for um a neck mass, uh, Probably something you're wondering is at what point do I need to refer and what should I try before doing that. So there are some things that you can try um in terms of like low-risk interventions for those masses that don't have any alarm features to them. Um, you can try if there's infectious symptoms, um, Uh, or, you know, physical exam features, you can consider a trial of empiric antibiotics. Um, we generally prefer Augmentin for a 10-day course for the majority of, um, subcutaneous neck masses. Um, and that has great coverage for, um, you know, both gram-positive and gram-negative, um, and for the most common things that are gonna cause, uh, like, you know, bacterial lymphadenitis. Um, If it's a really superficial, uh, infected mass, then considering that it could be MRSA, it could be staph aureus, you may wanna try Keflex, um, or if there's a high suspicion it's MRSA, then, um, clindamycin or Bactrim, um, for 10 days. And then you can, um, you know, Start their lab workup with some of these general labs that we talked about CBC ESR CRP, um, a strep if it, it's indicated, an EBV, um, to rule out mono, um, and then additional labs, um, based on their history. And then, um, always feel free to order an ultrasound to get a better understanding of what, what we're dealing with, with the mass. And then at what point should you refer to either ENT or in some cases to infectious disease or other services? Um, really, if there's kind of progressive enlargement that isn't improving over the course of two weeks or more, um, and, uh, particularly if there's, um, and they're on antibiotics and there's Worsening, um, rather than improvement. That's, uh, an indication for referring on. Um, if there's ever signs of severe infection such as like a fever, uh, that isn't going away, um, difficulty moving their neck or limited range of motion, um, and of course, difficulty breathing or difficulty swallowing, those should be really sent to the emergency room for, for Expedited workup. Um, and then if the, if the mass fails to spontaneously improve or resolve after 6 weeks, um, that is certainly a reason to have them, uh, seen by ENT or if there's any other symptoms that make you concerned that there might be something not, um, purely benign and potentially malignant going on. So what happens after you refer them to ENT and we see them, what we will often do is, um, first of all, determine if there's other referrals that need to be made, so interventional radiology for help with, um, like an FNA or coordinated biopsy, infectious disease, for example, if it seems like it's an atypical mycobacterial infection, um, and then obviously oncology as needed. Um, We will often do additional lab or imaging workup, um, and then if, if it's indicated, um, we'll perform an open excisional or incisional biopsy, um, and then, and then, uh, you know, whatever is indicated for surgical management. So if we circle back to the cases um that I presented over the course of this talk, um, and just kind of close the loop, so the first case, um, you know, they were sent on to ENT and uh when we saw them, we put in a referral for an FNA, um, given that the, um, you know, given that it had been around for, um, several weeks, um, without improvement, and then Um, based on the fact that even benign FNAs have a, a very small false negative rate, um, we often will order kind of interval imaging, so another ultrasound, um, in about 6 months just to make sure that there's no change, um, and continue to follow them. Um, for case number 2, it turned out that when we got an MRI for, um, for that mass, it was a 4th brachial cleft cyst. Um, and so they were taken to the OR for, um, for direct laryngoscopy, um, and what you're seeing here, um, over here is the airway, and this is looking at kind of the side wall of the pharynx, um, and so the glottis is over here. What you're seeing here is the pyriform sinus and you see this little tiny hole that's the opening of the sinus tract, um, and the way that fourth branch cysts are managed when we find a sinus tract like this is actually with, um, cauterization of that hole which closes off, um, the cyst and causes it to extinguish and sometimes we'll help that along by aspirating, um, the cyst itself, uh, and, um, at the time of the cauterization. And then for case number 3, that ended up um getting a CT with contrast which demonstrated that, you know, again that there are these multiple abnormal level 2 lymph nodes as well as in levels 3 and 4. they were sent to get an FNA and that returned as atypical lymphocytes but it was not diagnostic, um, which is sometimes the case, uh, for, for this and so then, um, The plan was to do an excisional biopsy to get more um tissue for diagnosis. Before going to the OR anytime there's a suspicion for lymphoma um or a systemic um malignancy, we always get a chest X-ray to make sure that there's no bulky mediastinal disease which can Um, which can cause airway compromise intraoperatively when they get induced under anesthesia. Um, and so, and then they got taken for an excisional biopsy of one of these lymph nodes, um, came back as Hodgkin's lymphoma and were sent on to see oncology for treatment. So, um, I just wanted to switch gears a little bit, um, before I end, um, by, uh, By talking a little bit about um ENT kind of common diagnosis in general, I think we're in the same boat in our ENT group as many of you probably are, um, where post-COVID, we saw this huge surge in, um, in patient referrals, um, and patient visits and, um, and so we've been working on ways to improve access, um, to our, to our ENT clinic and Um, and one of those ways that we've come up with is by putting together some guidelines of things that um you as a primary care, uh, um, provider can try before referring them to see us and honestly these are um These are basic but really effective interventions that are often what we would recommend anyway during our first um visit with these patients. Um, so, uh, there's, um, you know, for patients who have like nasal congestion. Chronic nasal congestion that won't go away even after they have a cold and the cold gets better, um, we will recommend doing a 6-week trial of some, um, saline and then Flonase sprays, um, and it has to be like consistent use of Flonase on a daily basis for about 6 to 8 weeks to get the full benefit of it. Um, for this context. Um, similar idea for patients who have either like big tonsils or adenoids and then, um, snoring but not really any other, um, symptoms that are concerning for like severe, severe sleep apnea. So, um, those would be like, like actual pauses in their. Breathing or respiratory distress, things like that. So for your patients who just kind of have run of the mill snoring, you can try Flonase in a similar fashion, um, and uh we recommend doing uh the Sensimist Veramyst half dose of um of steroid spray for patients who are under the age of 4. and for patients who have ephystaxis, um, Uh, trial of um increasing moisturization to, um, to control their bleeding and get the blood vessels to heal off. Um, Uh, can be, can be very effective. Um, so 4 weeks of using saline sprays on the nose, Vaseline and Aquaphor on a daily basis, um, and then of course avoiding any digital trauma or sprays up the nose other than the saline, um, and management of acute nosebleeds. Um, this is basically, you know, what we tell all of the patients that come in to see us for, um, epistaxis, um, and what we would try before moving on to cauterization. Um, and then for serumin impaction, it can be very helpful even if they do need to come to see us to have like a really bad serumin impaction removed. It's often helpful to get them started with a four-day trial, um, of, uh, Debrox in the ear. You don't wanna use Debrox, it's sort of like a hydrogen peroxide, um, drop. You don't wanna use it if they potentially have a perforation or hole in their eardrum cause it can be odotoxic. Um, but if, um, you know, it's, if it's sort of run of the mill, um, earwax, then you can consider using that. Um, and then Certainly for patients who have, you know, truly urgent ENT issues, we get them seen. We have actually a system in place where we have a hospitalist of the week, and that's one of our ENT MDs who is solely responsible for that week for triaging and Uh, and seeing patients who have urgent issues either on an inpatient or outpatient basis, um, and then taking them to the OR, um, during, you know, that same week as needed, um, if indicated. Um, and so I just wanted to share some of the criteria that we use from our perspective, uh, for, um, figuring out what constitutes a truly urgent, um, referral, um, and For otitis media, um, it's generally if they have been treated with multiple courses of appropriate antibiotics, um, and are not responding to it. And so they're continued to have actual like purely acute otitis media, um, then that would be definitely a reason, um, to send them on to see us urgently. Um, if, uh, if they have a sleep study for, um, suspected sleep apnea that shows that they have severe sleep apnea, um, that's a patient that we'll typically see urgently to, um, to get them, uh, uh, surgically managed, um, on a more, uh, immediate basis. Um, nasal fractures, so if they occurred within the past 10 days, then Uh, then we can often take them to the OR and do a close reduction um within that 10-day period, um, with good results. But if the injury was longer than 10 days ago, that probably would be a routine referral, um, that, um, needs to have a more extensive, um, uh, surgery to fix their fracture, um, because at that point, the cartilages and their bones will have already set. Um, and then for nosebleeds, if there is, you know, a significant amount of bleeding, um, then, uh, and, you know, it's causing anemia or anything like that, then, um, that would be something that would be seen urgently. For tongue tied, um, patients, those that are under the age of 6 months who are having trouble with, um, breastfeeding or bottle feeding and, and maintaining their weight, um. And, um, and then if you see a patient who has like a congenital ear um deformity of their pinna of the external ear, um, those patients need to be seen urgently within the 1st 6 weeks of life so that their cartilages don't set. Um, and are still moldable. So we can easily correct most of those malformations with some ear molding, um, which is very non-invasive, um, if we catch them before age 6 weeks. And, um, and then if there's a foreign body in the ear, um, we generally will try to get them seen within about 2 weeks. Um, if there's drainage or if there's A lot of pain, then we'll see them more urgently than that. Um, and then if you have a patient who has like a ruptured eardrum from trauma or from an infection, um, those are usually gonna be seen on a routine basis and after, um, we recommend after you have tried some antibiotic eardrops, seeing them back about two months later, um, because oftentimes these Almost always actually these eardrums will heal on their own if it's um if it's a traumatic or infectious etiology. If they don't, then absolutely feel free to refer on to us. So that's all I have for you today.
