with Jennifer Chapman, Children's National, on the Hot Seat
Case edited by Emily Willner
The Case
Birth-history: full-term born NSVD w/o complication. Mother received prenatal care. NBS negative. +2 mo imm
Exam: T 36.8 R // HR 135 // BP 92/64 // RR 32 // 98% on RA
Pt is comfortable in mother’s arms, interactive and responding appropriately.
HEENT: EOMI. No pharyngeal erythema. Marked swelling noted over right cheek w/o erythema or other skin color change. +TTP. Not warm to touch. Maximal swelling is anterior to parotid gland and does not extend over mandible. Skin is very taut and swollen area feels tense and firm, not fluctuant. No dentition noted. TMs clear b/l.
No cervical LAN
CTAB, normal WOB.
CV exam WNL.
Abd soft, nontender, no HSM.
Skin: atopic dermatitis noted over extremities.
Ext: No swelling, no TTP, pulses 2+ in 4 extremities.
Given the unusual appearance, you obtain an ultrasound showing a collection of free fluid within the soft tissues of the cheek with some small debris, no clear sepatations to suggest abscess, no discernable mass.
Questions for you (answer question associated with your PEM experience)
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About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
Essentially, we have acute (<6 hours) onset of right cheek swelling without systemic signs of infection or trauma or clear etiology suggested by H&P and initial ED evaluation (US). I would start by asking radiology what differential the US findings (of "free fluid within the soft tissues of the cheek with some small debris, no clear sepatations to suggest abscess, no discernable mass") are most consistent with. Next, I'd get a better history. 90% of the diagnoses we make in the ED should be suggested by the history. Could this be subcutaneous fat necrosis from minor trauma or exposure to cold (outdoors, ice, etc.)? Could this be an allergic reaction to a cream/ointment? If the above approaches are unhelpful, I'd consider an ENT consult.
ReplyDeleteReally? ENT consult?
ReplyDeletethere aren't that many things that cause pain.
fat necrosis does not. urticaria does not.
it's similar to the importance of differentiating lymphadenopathy from lymphadenitis........you don't need an ultrasound or CT for that!
to me, pain equals: broken bone or clot or infection or contusion.
it's great to make sure the swelling doesn't cross the angle of the mandible as you'd see with partotitis. I would try to localize the distribution to lymph nodes or in the distribution of congenital anomalies (sinus tract? brachial cleft cyst? cystic hygroma?)
but it sounds like an infection to me.
I guess I'd send coags because it's a boy and theoretically this could be the first presentation of hemophilia if he bled into his cheek. but I've never heard of that.
For me, it depends on how much you trust your history.
ReplyDeleteTRUE history (<6 hours onset):
More likely: salivary gland cyst, blocked salivary duct (stone, infection, mumps), bleed/hematoma, fracture.
Less likely: tumor (name your -oma), infection (abscess, buccal cellulitis, parotiditis; unlikely given not red or hot, but re-examination might find one of these esp as very young infants not always manifesting the rubor/tumor/dolor/calor)
Not: branchial cleft cyst (b/c this kid's location is too high on the face above mandible), subcut fat necrosis (this kid is non tender, and SFN doe not have rapid growth)
Not trusting your history:
--> Add the "less likely" back on to DDx, as fever hx now unreliable (never checked, grandma gave tylenol, etc.), timing now unreliable (tumor higher up), abuse hx unreliable (now frx, hematoma higher).
Hx would dictate management. Because time is the great healer and great killer, the kid is definitely getting admitted given rapidity of sx. Get your CBC/BCx (if very high/low WBC, reassess need for full septic w/u in case of buccal cellulitis from Hib/Staph), Coags, recheck VS, get consults cooking (likely leading to MF CT with w/o contrast), admit to gen med.
To summarize, this is a healthy FT 3mo with 6 hours of one-sided cheek swelling. Possibilities include infection, trauma, congenital anomaly and malignancy. In order:
ReplyDelete- Infection: even before my time, Hflu caused a classic cellulitis in the cheek from hematogenous spread. The baby’s incomplete immunization against Hflu is his major risk factor for this infection- not race or gender. What supports infection is the relatively rapid onset and the tenderness, while the lack of redness and lack of fever go against it. Other infections: abscess related to a break in the skin and cellulitis related to odontogenic infection- neither is well supported by the physical exam.
- Trauma: a not very traumatic cause of this type of exam in older children is popsicle panniculitis- the cold from the popsicle resting inside the cheek injures the fat and causes an inflammatory change. Nothing needs to be done after establishing the history of cold exposure. As for other trauma leading to swelling, the exam doesn’t demonstrate signs of bruising or skin breaks that would make me think of an injury to the cheek.
- Congenital anomaly: there are a variety of congenital anomalies that could cause swelling of the cheek, including a cyst within the soft tissue or related to the parotid gland, an adenoma of the parotid gland, a lymphatic abnormality, a hemangioma, probably many others. What would speak against these is the rapidity of onset of the swelling, though sometimes cystic abnormalities do suddenly enlarge with infection or trauma.
- Malignancy: rhabdomyosarcomas can arise from any muscle, with the face/neck being a common site (I think the pelvis is most common). But this is much more common in older children/adolescents and I wouldn’t think of it as readily in a 3mo.
How does the US help? The free fluid makes cellulitis and solid tumors less likely. Abscess still not as likely given the exam. So the US leads more towards a congenital anomaly.
Plan: have to commit to whether I think this is an infection- since this is the most serious concern in this young infant. On my bold day, I would not do bloodwork and not admit. I would ask ENT for their input on what might cause this isolated, noninfectious fluid collection. I would also involve the PMD around follow-up and recommended imaging/ENT follow-up. On a worried day, I would get a cbc and BCx and admit for observation, with discussion with the Hospitalist around not starting antibiotics unless the baby develops a fever and around what further imaging might help. In practice, I might phone-a-friend and get another PEM physician’s input.