PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting at the National Conference and Exhibition I will be sharing four cases online in advance of the conference. This is the second of the four cases.
This case was submitted by…
Dr. Walker was assisted on presenting this case by Morgan Bowling, MD, a Pediatric Emergency Medicine Fellow at Newark Beth Israel Medical Center and Children’s Hospital of New Jersey and Ravi Thamburaj, MD, a Pediatric Emergency Medicine Attending Physician at Newark Beth Israel Medical Center and Children’s Hospital of New Jersey.
A 14-year-old male presented with sore throat and difficulty swallowing. His symptoms started approximately one month prior to presentation but had progressively worsened, leading to voice hoarseness and weight loss due to dysphagia. He had been referred to the otolaryngology (ENT) about one month prior from his pediatrician who prescribed a course of oral steroids and cephalexin, which he took as prescribed, with no improvement in symptoms. He had been scheduled for a future tonsillectomy.
On initial exam, he was tachycardic to the 120s, in mild distress but afebrile, maintaining normal oxygen saturation on room air. He was in distress secondary to pooling of secretions and in moderate pain. His voice was hoarse. His throat exam was significant for bilaterally enlarged tonsils without exudate or deviation of the uvula. There was no appreciable swelling of the jaw or face but there was some right sided, mildly tender lymphadenopathy. He had no stridor or trismus but did have a “hot potato” voice. The patient had significant pooling of phlegm and saliva. With suctioning of the copious secretions, a tan, irregularly bordered mass was visualized in the posterior pharynx. His lung exam showed clear breath sounds bilaterally. His cardiovascular exam was significant for only tachycardia with a regular rhythm. His abdomen exam was negative for hepatosplenomegaly. Remainder of exam including neurological exam was normal.
Initial labs were significant for:
- White blood cell count 18.6 x 103/mcL
- High hemoglobin and hematocrit, 15.3 g/dL and 46.3% respectively
- Platelet count was 435 x103/mcL
- Low MCV of 73.3 fL
- Renal panel – Sodium was 137 mmol/L, potassium 4.6 mmol/L, chloride 100 mmol/L, Co2 31.0 mm/L, calcium 10.6 mg/dL, glucose 103 mg/mL, BUN 13.0 mg/dL, creatinine 1.040 mg/dL
- Liver profile – Bilirubin 0.4 mg/dL, albumin 4.0 g/dL, ALT 18Unit/L, AST 11 Unit/L, alkaline phosphatase 142 Unit/L
- Mononucleosis screen, COVID-19, flu, and rapid strep negative
- Throat and blood cultures were obtained
Coronal CT of the neck with contrast
Saggital CT of the neck with contrast
Computerized tomography (CT) of the neck with contrast was performed which showed 4.6 x 4.2 x 7.6 cm (AP x TRV x CC) heterogenous lesion anterior to and separate from the prevertebral soft tissues. Multiple vascular structures were seen within this lesion as well as a 3 cm cystic and /or necrotic component. There was significant narrowing of the oropharynx/ airway to approximately 4 mm over approximately 4 cm in length extending inferiorly from the level of the epiglottis. There was no nasopharyngeal, oropharyngeal, or base of the tongue mass. There were no masses seen in the hypopharynx or larynx. The trachea was patent and midline. There were no masses within the parapharyngeal or masticator spaces. There were small bilateral submental (level IA), submandibular (level IB), jugular chain (level II through IV), and the posterior triangle (level V) lymph nodes, which do not meet CT criteria for enlargement. There was a 1 cm spiculated noncalcified solid nodules in the left upper lung lobe.
Due to findings on the CT scan, ENT was consulted and evaluated the patient at beside in the pediatric emergency department and performed a flexible laryngoscopy which did visualize the mass but could not fully visualize the remainder of the oropharynx but could not clearly delineate the diagnoses but was concerning for possible malignancy.
The patient was initially admitted to the local PICU, and later transferred to a quaternary facility with specialized ENT services where the ultimate diagnosis was made.
A. Peritonsillar Abscess
B. Palatal Torus
C. Synovial Sarcoma
D. Arteriovenous Malformation
E. Lymphangioma