2025 Pediatric Surgery Update Course - Updates in Management of Neck Pathologies

CT scans are frequently performed in the emergency department for neck swelling before surgical consultation

Incision and drainage of branchial cleft cysts can make future surgical removal more challenging

Type 3 and type 4 branchial cleft cysts typically have a tract going up to the piriform sinus

Type 3 and type 4 branchial cleft cysts can be associated with thyroiditis and may require hemithyroidectomy if the lesion is stuck to the thyroid during excision

Endoscopic cauterization of the piriform sinus tract can resolve branchial cleft cysts and prevent recurrence

For endoscopic cauterization of piriform sinus tracts, only the tip (about a centimeter) needs to be cauterized, not the whole tract

Endoscopic approach for branchial cleft cysts can avoid morbidity of open approach including thyroid resection and recurrent laryngeal nerve injury

When placing bulk tissue for interposition in TEF repair in younger children or those with posterior tracheal wall intrusion, excessive bulk can worsen obstruction

Trans-tracheal repair of high TEF involves making a tracheotomy over the fistula, dividing esophageal and tracheal layers through the tracheotomy, closing the esophageal side, placing interposition graft, and achieving three-layer closure

Recurrent laryngeal nerve injury is under-reported and requires regimented protocols with pre- and post-operative evaluation

Aspiration of cystic neck masses with amylase testing to differentiate ranula from lymphatic malformation has technical challenges: labs have trouble running thick fluid, and lymphatic malformations near glandular tissue can have saliva leaching causing false positives

Removal of the sublingual gland is the best practice for ranula treatment; cervical components should resolve after sublingual gland excision because ranulas are pseudo-cysts

Micro-marsupialization for ranulas involves placing silk sutures through the cyst for 30 days to develop a fistula, then cutting the sutures to allow spontaneous drainage into the mouth

PIK3CA mutations in lymphatic malformations indicate that alpelisib (a PI3K alpha inhibitor) can be useful for treatment

VanSEAT gene panel run in Seattle is the most comprehensive panel for lymphatic malformation genetic testing

Alpelisib cannot be used until patients are 2 years old; current practice is to use sirolimus until patients are eligible for alpelisib

Congenital developmental neck masses require addressing the embryological component or etiology, not just mass excision, to prevent recurrence