SAEM Clinical Image Series: A Recurring Neck Mass

A 30-year-old female with no significant past medical history presents to the Emergency Department with a six-day history of an enlarging, tender, red “bump” on her anterior neck. She reports similar swelling during bouts of pharyngitis. She also reports a recent upper respiratory infection one week ago that was marked by fever, cough, congestion, sore throat, and myalgia. She denies shortness of breath, neck trauma, travel, or animal exposures.

Vitals: T 37°C; BP 122/78; HR 77; RR 17

General: Well-developed, well-nourished female in no acute distress

HEENT: 2cm tender, fluctuant, mobile right anterior neck mass with surrounding erythema; no drainage noted; mass does not move with swallowing

The remainder of the exam is unremarkable.

Non-contributory

Second branchial cleft cyst

Branchial cleft anomalies are the second most common type of congenital neck mass and present as cartilaginous remnants, sinuses, fistulas, or cysts due to the failure of the branchial apparatus to obliterate. The most common are second branchial cleft anomalies, representing 95% of these cases. Second branchial cleft anomalies are usually located along the anterior border of the sternocleidomastoid muscle on the left side of the neck.

Differential diagnoses include thyroglossal duct cyst, neck abscess, cystic hygroma, cervical lymphadenopathy, metastatic lymph nodes, and cat scratch disease.

The gold standard of treatment necessitates complete surgical excision of the entire branchial cleft anomaly. Branchial cleft anomalies are most commonly diagnosed with computerized tomography (CT) that shows a uniformly hypo-or-anechoic mass with well-defined margins and thin walls. Preoperative fine needle aspiration cytology can be used to view histopathological findings of the mass and help to rule out malignant disease. Ultrasound and MRI can also be helpful for diagnosis, preoperative localization, and preoperative identification of surrounding structures. However, for definitive diagnosis, surgical excision of the entire anomaly and pathology examination is required. If full resection is not achieved, recurrence is possible.

Take-Home Points

  • A branchial cleft anomaly is the second most common type of congenital neck mass.
  • Branchial cleft anomalies are due to failure of the branchial apparatus to obliterate and can present as cartilaginous remnants, sinuses, fistulas, or cysts.
  • The gold standard of treatment requires complete surgical excision of the entire branchial cleft anomaly to prevent recurrence.
  1. Muller S, Aiken A, Magliocca K, Chen AY. Second Branchial Cleft Cyst. Head Neck Pathol.2015;9(3):379-383. doi:10.1007/s12105-014-0592-y Zaifullah S, YunusMR, See GB. Diagnosis and treatment of branchial cleft anomalies in UKMMC: a 10-year retrospective study. Eur Arch  2013;270(4):1501-1506. doi:10.1007/s00405-012-2200-7

 

By |2021-08-20T09:57:47-07:00Aug 23, 2021|HEENT, SAEM Clinical Images|

SAEM Clinical Image Series: Sudden Onset of Facial Petechiae in Kindergartener

petechiae

A 6-year-old boy with no past medical history presented when his parents noticed facial petechiae after picking him up from school. He had a series of four recent upper respiratory infections within four months since starting public kindergarten. He occasionally also complains of leg pain.

General: Non-toxic, cooperative child

Skin: Petechial rash in periorbital and infra-auricular areas

HEENT: Normal; no lymphadenopathy

Musculoskeletal: Normal strength and range of motion

Hemoglobin: 12.6 g/dL

White blood cell (WBC) count: 6.7×103/mL

Platelets: 352,000/mL

Increased pressure in the dermis from actions such as extended Valsalva maneuver, vomiting, crying, or coughing.

This child had a stressful day in kindergarten. He was holding his breath for extended periods of time to suppress crying. The increased pressure caused the facial petechiae, which was completely unrelated to his recent viral infection or growing pains

Take-Home Points

  • Fine petechiae around the eyes, cheeks, and ears are most often caused by crying or similar behaviors that cause increased pressure in the subcutaneous vessels of the face.
  • Mucosal and cutaneous capillaries are fragile and can easily rupture, even with minor trauma. Usually, platelets can seal these immediately, so when petechiae show up, consider a problem with primary hemostasis.
  1. Kumar V, Abbas A, Aster J. Hemodynamic Disorders, Thromboembolic Disease, and Shock. Robbins & Cotran Pathologic Basis of Disease, 10th edition. 2021. Marcdante K, Kliegman R. Immunological Assessment. Nelson Essentials of Pediatrics, 8th edition. 2019

 

 

By |2021-07-22T22:10:34-07:00Aug 9, 2021|Dermatology, HEENT, Pediatrics, SAEM Clinical Images|

SAEM Clinical Image Series: Facial Edema

facial edema

A 44-year-old female presents to the emergency department after noticing swelling of her tongue and face, specifically the cheeks and periorbital area. She states the swelling began two weeks ago and has progressively worsened. She also complains of redness.

Vitals: T 38.6°C; BP 135/78; HR 90; RR 18

General: Lying in bed, somewhat anxious appearing

HEENT:

  • Significant edema of bilateral cheeks and periorbital areas
  • Thinning of hair along scalp and lateral aspect of eyebrows
  • Mild macroglossia

Skin:

  • Yellow tinge to patient’s skin
  • Horizontal scar noted on the anterior aspect of the neck

TSH: 31.27 mU/L

Free T4: 0.20 pmol/L

Myxedema facies

This patient has a history of thyroidectomy, as indicated by her neck scar, and a history of noncompliance with levothyroxine.

Myxedema is a term used to describe the appearance of nonpitting edema in patients with severe hypothyroidism. While the exact mechanism is not completely understood, this edema is thought to be secondary to increased deposition of dermal hyaluronic acid, a glycosaminoglycan that can grow up to 1000x its normal size when hydrated. Carotenemia is another possible manifestation of hypothyroidism and is secondary to impaired conversion of carotenoids to retinol in the setting of low levels of thyroid hormone. Additionally, patients may exhibit patchy alopecia, fatigue, cold intolerance, goiter, coarsening of the skin, and macroglossia.

Take-Home Points

  • The presentation of hypothyroidism is widely variable and may be subtle or atypical. Classically, hypothyroidism presents with pretibial myxedema, hyporeflexia, and cold intolerance. In some cases, facial edema may be the predominant feature, as seen in this patient.
  • Brittle, thinning hair on the scalp and eyebrows is a common feature. Thinning of the hair along the lateral eyebrows is called madarosis, also known as “Queen Anne’s Sign.”
  • In a patient with Grave’s disease, maintain a high index of suspicion for hypothyroidism, either as part of the natural history of the disease or as a sequela of treatment.
  1. Safer JD. Thyroid hormone action on skin. Dermatoendocrinol. 2011 Jul;3(3):211-5. doi: 10.4161/derm.3.3.17027. Epub 2011 Jul 1. PMID: 22110782; PMCID: PMC3219173.
  2. Wiersinga WM. Adult Hypothyroidism. 2014 Mar 28. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, Dungan K, Grossman A, Hershman JM, Hofland J, Kalra S, Kaltsas G, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, McGee EA, McLachlan R, Morley JE, New M, Purnell J, Sahay R, Singer F, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000–. PMID: 25905416.

 

 

SAEM Clinical Image Series: What’s This Thing on My Face?

A 91-year-old female patient presented with her family after concern for multiple new lesions on her face and hands. The patient thinks the lesions grew over the course of a few months. There is no pain at the sites, no erythema, and no pruritis. She has caught the lesions on clothing and bedding, which has irritated the lesions on occasion, and the family is concerned/embarrassed by the growths on her face, which are harder to conceal than those on her hand.

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By |2021-02-21T07:51:46-08:00Feb 22, 2021|Academic, Dermatology, SAEM Clinical Images|

SAEM Clinical Image Series: Guess Who’s Back?

rash

A 27-year-old male with no significant past medical history presented to the emergency department with one week of progressively worsening, non-pruritic, and intermittently painful rash to his bilateral dorsal and plantar feet. The patient also described lesions to his left inguinal region and scrotal sac. There was no fever, chills, nausea, vomiting, chest pain, or shortness of breath. The patient was sexually active with men and women, with inconsistent condom use.

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SAEM Clinical Image Series: Finger Pain

finger

The patient is a 24-year-old female who presents to the emergency department for left middle finger pain and swelling. She is right hand dominant and works in a kitchen. The patient states that ten days ago she avulsed the distal tip of the left middle finger, including the majority of the nail. At that time, the patient was evaluated at an outside hospital where the wound was cauterized with silver nitrate due to soft tissue bleeding. Since then, the patient states that she has had swelling over the dorsal distal phalanx.

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SAEM Clinical Image Series: Edema Got Your Tongue?

angioedema

A 57-year-old male presented to the emergency department with a swollen mouth for three hours. He reported never having experienced this before and denied starting any new medications. The patient endorsed a feeling that his mouth was swollen and had difficulty swallowing. The edema had been increasing in size since its onset. He had been drooling for the past hour and endorsed mild pain around the area. He denied any shortness of breath, rash, nausea, vomiting, or other areas of edema. His past medical history included hypertension, diabetes, and allergies, with no known drug allergies. His family history was unknown. His medications included Metformin and Lisinopril.

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