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Pediatric Otolaryngology |
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Table of Contents
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Children are special people. They have unique anatomy, unique personalities and unique illnesses. The psychological and physical health of a child is mandatory for normal growth and development and is critical to adulthood success both professionally and personally . The following is written to provide general information regarding pediatric illness involving the ears, nose and throat. Specific application requires consultation with your pediatrician or your head and neck surgeon. Otolaryngology/head and neck surgery is a surgical specialty. It encompasses diseases of the ears, nose and throat. The specialty has undergone numerous name changes. Originally the specialty was known as otorhinolaryngology. As this was cumbersome for the general public, it was called ear, nose and throat and abbreviated ENT. With the expansion of the capabilities of the specialty, alternate names were suggested. Head and neck surgery was one, otolaryngology was another. Consensus was never reached and the official name of the specialty is currently otolaryngology-head and neck surgery, however, most of us still recognize and answer to the older title ear, nose and throat (ENT). The otolaryngology-head and neck surgery specialty is divided into sub-specialties. The common sub-specialties are otology (ear disease), rhinology (nasal disease), laryngology (voice disorders), head and neck surgery (head and neck cancer), facial plastic and reconstructive surgery and pediatric otolaryngology. For children, there is always great discussion whether a given illness is best treated by an individual sub-specialized in pediatric otolaryngology or a general otolarynongologist trained, skilled and practiced in pediatric disease or by a sub-specialist, specially trained in disease of the afflicted organ. Is a two year old with chronic ear disease best managed by a pediatric otolaryngologist or by an otologist? Is a child with chronic sinusitis best treated by a pediatric otolaryngologist or a rhinologist? Is a child with a cleft lip best treated by a pediatric otolaryngologist or by an individual specialized in facial plastic and reconstructive surgery? There is no right answer. Everyone has special skills, special strengths, special aptitudes and special preferences. It is therefore left to the team of parents, pediatricians and physicians to choose the right people and the right treatments. The following file is organized in the traditional fashion of ears, nose and throat diseases. Questions and comments are always appreciated.
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The
ear is divided into an external ear, a middle ear and an inner ear. The
ear is responsible for hearing and contains the vestibular organs,
namely the semicircular canals which assist in balance and orientation.
The external ear includes the auricle, that part of the ear containing
skin and cartilage which protrude from the side of one's head and the
external auditory canal, a cartilaginous and bony structure which
directs sound to the tympanic membrane. The external auditory
canal contains small hairs and excretes wax which coats and protects the
skin of the external auditory canal. At the medial or inner extent of
the external auditory canal lies a very thin membrane. It is 5 to 7 mm
in diameter and less than half a |
Young children love to experiment and sample the world by placing anything they can in their mouth, their nose and their ears. Occasionally, one of these ends up becoming stuck. The most common foreign bodies for the ear canal are small beads, pencil erasers and other similar sized toys. Once stuck, they generally require removal by a physician. This is often easily accomplished by the pediatrician, but in more difficult cases or in those children in whom the foreign body has now been pushed deep into the canal and may be against the tympanic membrane, removal by an otolaryngologist is required. This can require a microscope and a general anesthetic.
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Otitis Externa (Swimmer's ear)
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The symptoms of swimmer's ear are pain, itching and occasionally hearing loss. Swimmer's ear is a result of the change of the normal pH balance of the external auditory canal. This occurs from excessive use of Q–tips with resulting damage to the epithelial or skin lining of the ear canal or most commonly in children from long periods of water emersion such as happens at the beginning of summer or on trips to water vacation destinations. Due to the trauma of the Q–tips or the soaking of water emersion, the normal acid pH of the external auditory canal is lost. Psuedomonas aeruginosa is a normal bacterial inhabitant of the external auditory canal. The bacterria's growth is inhibited by the acid pH. When the acidity is lost the Psuedomonas bacteria proliferates. This causes a superficial infection with resultant pain, itching and discharge. The standard treatment is an ear drop. The ear drop typically contains an acidifying agent and a drying agent. The home remedy ear drop contains equal parts of white table vinegar, 70% isopropyl alcohol and water. Commercial preparations are available over the counter and by prescription. The prescription drops contain antibiotics and steroid additions which are felt by many to enhance the ear drop efficacy. Oral antibiotics are not indicated, are not helpful and should neither be requested nor prescribed. There is no question that this is a painful condition. Pain medicine such as Tylenol for young children, aspirin and non-steroidals for older individuals should be provided. Heat is also very comforting. In the old days this was a stone warmed in the fire. Today it is a dry heating pad. The ear drops are used until the pain and itching are gone. They can be used 3-4 times a day. Once improved, the child can return to swimming, bathing and normal activities. In very difficult cases, accumulated debris may need to be suctioned or washed out of the ear canal. This can be performed by the pediatrician or by the otolaryngologist. In advanced cases where the ear canal is literally swollen closed, drops will not reach the inner portions of the infected canal and so a small sponge wick will be inserted. These normally stay in place for 1-4 days. Drops placed in the external canal are carried along the wick. Otitis externa should respond to treatment in 12-24 hours. If it does not, and certainly if it progresses, this is not only a serious discomfort, but a medical emergency and should be brought to the attention of the appropriate physicians.
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All children suffering from acute otitis media should be checked by their physician after approximately one month to make sure that not only has the infection cleared, but that the fluid has drained and that hearing is restored to normal. If it is not, hearing loss, learning disability and the potential for re-infection occurs. Additional treatment and attention will be required. For additional information look at the information on the AAO-HNS website on otitis media. Chronic otitis media is a very complex disease, typically initiated by perforation of the tympanic membrane. It is often a result of chronic eustachian tube dysfunction and middle ear negative pressure. The middle ear and mastoid become chronically infected. This condition leads to decreased hearing and potentially leads to facial paralysis, meningitis, brain abscess and death. Chronic otitis media is a serious illness and must be evaluated and treated. Evaluation includes consultation with an otolaryngologist. It is commonly treated with antibiotics and with ear drops. Hearing tests to document the degree of hearing impairment are mandatory. Ultimately, surgical repair is required to eradicate infection and protect and restore hearing.
Serous Otitis Media Serous otitis media is a very common illness of young children typically during the ages of 1 to 5, but occasionally extending through puberty and has been increasingly discovered in adults as well. A symptom of serous otitis media is hearing loss. You may recognize that your child doesn't respond when called to dinner. You may note that the child turns the TV or radio volume to a louder position. You may also note that the child misses words, has difficulty learning in school and in young children and more advanced disease, may even have difficulties pronouncing words. If left unattended, serous otitis media may result in permanent hearing loss, permanent learning disability and even a decrease in the child's intelligence quotient. Diagnosis and treatment are important. The normal treatments for eustacian tube dysfunction and serous otitis media include a thorough head and neck evaluation. Underlying problems such as allergic rhinitis and chronic sinusitis should be diagnosed and treated. Concurrently, the serous otitis media should be observed. Many treat with antibiotics. Many treat with nasal steroids. Some treat with anti-histamines and in all cases nature should be provided opportunity to resolve the serous otitis media. If after 6-12 weeks the serous fluid has not drained and the hearing loss persists, a hearing test and tympanogram are recommended. Indications for surgery are hearing loss and persistent negative pressure with retraction of the tympanic membrane. The hearing loss diagnosis is self explanatory. In serous otitis media, air does not reach the middle ear. There is therefore a constant negative pressure. The tympanic membrane is sucked inward. It is stretched over the ossicles and is thinned. This predisposes to chronic serous otitis media. This predisposes to chronic hearing loss. This predisposes to chronic otitis media and just as with hearing loss, surgical treatment is required. The surgical treatment for serous otitis media is simple. An artificial eustachian tube is made by making a small incision in the tympanic membrane aspirating the middle ear fluid and then inserting a small silicone or stainless steel endotracheal tube. This tube allows air to enter the inner ear and restores normal middle physiology. Fluid will drain initially out the tube, but ultimately through the eustacian tube. The incision is called a myringotomy. The tube is called a middle ear ventilation tube (MET). The myringotomy and insertion of ventilation tube is typically performed under general anesthesia. After appropriate preparation, the child is given an anesthetic gas to breath, they fall asleep quickly. A light anesthetic is all that is required and an endotracheal tube is not required. The otolaryngologist examines the ear with a microscope, cleans the wax and superficial debris from the external canal. A small incision 2mm or so in length is made in the ear drum, fluids of the middle ear are suctioned away. A very small middle ear ventilation tube is inserted and a prophylactic antibiotic ear drop is instilled. The anesthetic is turned off, the child awakens and is returned to the recovery room. The anesthetic was light, the duration was short, the intrusion was minor and children typically awaken very quickly and return to normal within a matter of hours. The first anesthetic and first myringotomy tube is always a major undertaking for both parent and child. If this becomes a repeated necessity, the subsequent procedures seem to be quite simple. The children remember little to nothing about the experience. There is no observed psychological consequence. The benefits are restored hearing, reduction of complications of the serous otitis media and restoration to normal speech and learning. As with all surgeries, complications can occur. None are common. In approximately 1% of cases a superficial infection with drainage can occur. These cases require topical ear drops. In some cases once the tube extrudes, which typically happens anywhere between 2 and 6 months, a permanent hole can persist. This is called a tympanic membrane perforation. When the child is older and the eustachian tube has grown and functions normally, the perforation will require surgical repair. There is heated debate regarding water and children with middle ear ventilation tubes. There are those who propose that the ear should be maintained dry. Ear plugs and other water precautions are taken. There are others who do not believe that water passes through the middle ear ventilation tube and that if it does, damage does not result. These physicians do not recommend water precautions. Water precautions are a matter of personal preference, a decision made both by the parents and the treating physicians.For those who would feel safer with water precautions, my favorite is the "Ear Band-It" ear protector available through the UCSD Head and Neck Surgery clinic or the Encinitas Pediatric Group. There are those who advocate adenoidectomy or tonsillectomy and adenoidectomy in the treatment of serous otitis media. There have been scientific studies conducted to answer these questions. The answer has not been forth coming. There is little evidence that tonsillectomy is of value in the management of serous otitis media, this is therefore rarely recommended. There are those that believe that adenoidectomy is important in restoration of normal eustachian tube function. My own recommendation is that children undergoing a second set of tubes have an examination of the nasopharynx under general anesthesia. If the adenoids are seen to be crowding and over growing the eustachian tube drainage into the nasopharynx, then adenoidectomy at the time of the second or third set of tubes seems warranted.
Congenital Hearing Loss and Deafness Congenital hearing loss and deafness are uncommon, but do occur. These are very difficult problems which require serious, sophisticated diagnosis and treatment. Early diagnosis and early intervention is strongly encouraged . Many excellent resources are available to the parents of children with congenital hearing loss. Consultation with a knowledgeable and caring otolaryngologist is mandatory.
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The bloody nose is a common problem. For most children it is the result of night time nose picking. Even if you can teach the child not to pick their nose during the day, they all pick it at night. A little Vaseline applied to the nostril 2 times per day will reduce crusting. Nose picking during the day should be discouraged. Nose picking at night is best prevented by placing the child’s hands in some form of glove during sleep. For some, batting gloves are easy to encourage, for others, wait until the child is asleep and then put their hands in loose garden gloves. However, nose bleeds can be the first and early warning signs of an underlying bleeding disorder such as hemophilia. If these occur frequently and if rather than stopping over a period of 5-7 minutes, continue for periods of 10, 15 and even 20 minutes, this should be brought to the attention of your physician and blood tests taken to test the parameters of coagulation. Allergies are very common in American populations. It is estimated that as many as 38% of the population suffers some degree of allergic rhinitis and as much as 10% suffers some form of asthma. Allergy is more common if one or both parents also have allergic rhinitis or asthma. Exposure to second hand smoke seems to increase the propensity to develop allergic rhinitis. An environment loaded with allergic stimuli appears to bring the disease on earlier and make it a more difficult case to treat. The classic symptoms of allergic rhinitis are sneezing, itchy eyes and clear, watery, runny nose. The hallmark of the treatment for allergic rhinitis is environmental control (several excellent commercial web-based stores are listed). Antihistamines have been often prescribed for allergic rhinitis. They tend to be sedating and many consider then ineffective. I myself, consider them to predispose to bacterial sinusitis. Once a child reaches 4-5 years of age, they can be treated with nasal steroids. These are topical steroids which are sprayed onto the nasal mucosa. The dose is extremely small. Only 1-2% of this is systemically absorbed and represents approximately a millionth of the body’s natural steroid production. It is therefore the author’s opinion that they do not behave like a systemic steroid and to the best of the author’s knowledge, they have no real side effects other than septal irritation and occasional difficulties with nasal bleeding. Older children can be taught to irrigate their nose with a Waterpik. Further description of nasal irrigation and its use in nasal disease is included in the Handbook of Nasal Disease. While surgical therapy, laser therapy included, is controversial in the management of allergic disease in adults, it rarely plays a role in the management of allergic disease in children. Skin testing and desensitization are always a consideration. They are, however, a major commitment of time and energy and should only be undertaken in the worst of cases. Sinusitis is classically a bacterial infection of the paranasal sinuses. The sinuses are mucosa lined air pockets in the facial bones. They are typically under and around the eyes. Many adults will develop sinus pains associated with colds. The anatomy and the disease is similar for children. Children may or may not complain of pain. However, in acute sinusitis they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some of the children may have mood or behavior changes. Most will have a purulent runny nose and nasal congestion even to the point where they become obligate mouth breathers.The infected sinus drains around the eustacian tube and so many of the children will present with serous otitis media. The standard treatment for sinusitis is antibiotics. Amoxicillan is the drug of choice. Occasionally stronger antibiotics become required. For acute sinusitis, 10-14 days is normally sufficient. For chronic sinusitis, longer courses, even 6-12 weeks, may become required. If medical therapy fails and the child is negatively impacted by the disease, surgery will often improve the situation. Consultation with an otolaryngologist is required. A sinus CT scan will then be ordered. If the child is too young to lie still for this, a general anesthetic will be required. Based on the history and the findings of the CT scan, the otolaryngologist can make recommendations about endoscopic sinus surgery. It is an excellent operation and for those who truly suffer from chronic sinusitis, is an important treatment. The operation requires a general anesthetic. The surgery is performed using little endoscopes and little microsurgical instruments all inserted through the nose. With this perspective and these instruments, little canals or tubes called ostia, which drain the sinuses into the nose, are opened and widened. Aeration and drainage are facilitated. Absorbable packing is typically used. Post-operatively the children are sleepy and uncomfortable for a day or two. Those old enough to irrigate their nose with a WaterPik will be encouraged to do so. Those too young to comply sometimes require a second anesthetic 2-3 weeks after the operation to inspect and clean the nasal cavity and the surgical areas. This surgery, like all operations, has risks and potential complications. These include infection, bleeding, scaring and even death from the anesthetic or from the operation. As the sinuses lie between the eye and beneath the brain, damage to these structures is a potential complication. Fortunately, the success rate is high and the complication rate low. Those individuals for whom the surgery is indicated, typically achieve substantial benefit. Polyps are rarely seen in children. When present, tests for cystic fibrosis are indicated. Uncommon problems such as polyps, papillomas, fungal infections and even benign or malignant tumors do occur, so when abnormalities exist, consultation and evaluation is always important. For more information about nasal dysfunction, you are encouraged to read the UCSD Nasal Dysfunction Clinic Booklet or the Handbook of Nasal Disease.
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Sore throats are common in adults. They are very common in children, particularly those in school and day care centers. Younger children will typically not complain of a sore throat. They will often have fever, mood changes and even lethargy. Younger children may have ear disease. Ultimately, the viral sore throat, also know as the common cold, will resolve into a runny nose. The nasal secretions are at first clear, but as they become superficially infected, will turn purulent, typically green or yellow. The children typically have swollen lymph nodes. Unless infection of the ear occurs, antibiotics are not indicated for the upper respiratory tract viral infection. Another sore throat illness is bacterial tonsillitis. The initial presentation is similar to that of a viral pharyngitis or upper respiratory tract infection. Examination by the physician should reveal that the infection is restricted to the tonsils, whereas in the viral pharyngitis, it will cover the tonsils and the pharynx. Some like to culture. I personally find it of little value. Decisions are best made by clinical presentation. In difficult or confusing cases one can err on the side of prescribing antibiotics. If tonsillitis becomes recurrent, or if an unusual condition called peritonsillar abscess develops, tonsillectomy becomes indicated. Tonsillectomy is major surgery. The children require general anesthesia with an endotracheal tube placed to protect their airway. While the surgery itself is easy to perform, the post-operative recovery includes a very sore throat for 3-4 days. Fluids, ice cream and a soft diet will be required. Whereas adenoidectomy or myringotomy have minor complications and a risk of death in the range of one per hundred thousand, tonsillectomy has more frequent risks and complications. The most frequent complication is post-operative bleeding. This can occur anywhere between 1 and 10 days after surgery. It is sometimes controlled in the clinic or emergency department, but particularly in children, often requires a return to the operating room. In 1 in 1000 cases the bleeding can be sufficiently severe to require a transfusion and while the numbers have not been reinvestigated in a long time, it is estimated that 1 in 20,000 children will die from the surgery, the anesthesia or the post-operative recovery. For those who need it, it is an excellent operation. For those who do not need it, it is an unneeded intrusion and an unneeded risk. Those undergoing tonsillectomy will typically have their adenoids examined. If the adenoids are enlarged, an adenoidectomy is performed at the same sitting and adds little time or morbidity to the surgical procedure. Sleep apnea is a newly diagnosed medical condition. It presents as snoring and even periods of gasping, choking, or stopping breathing during sleep. This interrupts sleep and can leave the child with significant mood change, ill behavior and learning difficulties. It also is the most common cause of bed wetting (enuresis) in children over the age of 5. It is estimated that approximately 10% of children snore and it is estimated that 2% of children have significant sleep apnea. If snoring, apnea episodes and mood behavior plus or minus bed wetting is present, it is reasonable to proceed to surgical therapy. If questions arise, these children may benefit from a sleep test. The easiest sleep test today is a multi-channel home sleep test, and is available through the UCSD head and neck surgery sleep laboratory. For those diagnosed with sleep apnea the treatment is tonsillectomy and adenoidectomy. This has a very high cure rate in children. In adults, medical treatment with CPAP is usually tried. This is not normally recommended for children. In addition, the uvula is commonly resected in adults as part of the tonsillectomy. While this can be performed if the uvula is exceptionally long and while to resect or not to resect makes little difference in the long term, the uvula can be preserved in pediatric tonsillectomy.
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Time invested preparing a child for an operation is time well spent. The more the child knows about what is to happen, the more comfortable they are and it is my perception, the better they do. The anesthesia is delivered typically with a sweet smelling gas administered through a mask very much like pilots and astronauts wear. The child then falls asleep, just as they do every evening. They feel no discomfort, they have no memories of the operation and are totally oblivious or unaware that surgery is being performed. Pre-operatively it is important that the child have neither aspirin nor any of the non-steroidal anti-inflammatory agents such as Motrin for two weeks prior to surgery. If the child takes other medications which may affect bleeding, these should be discussed both with the pediatrician and with the ENT surgeon. The child can eat and play normally the day before surgery. The morning of surgery the child should have nothing to eat and for early morning surgery, nothing to drink. For later morning surgery, clear fluids such as flat 7-up or water may be taken. Murky or opaque fluids such as milk, orange juice or tomato juice, are not safe and should not be offered to the child. Different surgeons and different anesthesiologists have different philosophies regarding fluids the day of surgery. These should be discussed and respected. Post-operatively, your child will be watched in the recovery room for a minimum of 2 hours. The one exception is myringotomies where they can be sent home earlier. Pain medications are typically Tylenol and codeine. The codeine should only be used if the Tylenol does not work and the child is in substantial discomfort. It is important to encourage fluids once the child awakens. Flat 7-up is the premiere post-tonsillectomy drink. Caustic fluids like orange juice and grape juice are poorly tolerated. Milk products cause too much mucous. Gum chewing should be encouraged for this facilitates rapid healing. The next day (the day after surgery), the child can eat whatever they want. Most have sufficient soreness that eating is not a priority. Ice cream is the premiere post-tonsillectomy food. Vanilla and chocolate are the two favorite flavors. Fruit flavored ice cream, yogurts and sherberts are acidic and cause undue discomfort. This is not a time to worry about healthy foods, this is a time to encourage fluids and encourage cold nutrition. Gum chewing facilitates healing and good fluid intake decreases the risk of post-operative bleeding. Most children return to a somewhat normal diet between 3 and 5 days and can return to school after 5 to 7 days and to normal physical activities between 10 and 14 days. Antibiotics are not typically prescribed following tonsillectomy. An occasional child will develop a mucosal infection, this typically presents between 3 and 7 days. The symptoms are a child who has been doing relatively well, developing increasing discomfort, decreasing fluid and food intake, and on examination the mucosa in the back of the throat appears red, an inflammatory response to the mucosal infection. For these cases, a return to the doctor is important. Antibiotics typically resolve the infection rapidly. Neither aspirin nor non-steroidal anti-inflammatory agents including Motrin, Advil or Ibuprofen should be taken in the post-operative period for a minimum of 2 to 3 weeks. As these products are rarely recommended for children, particularly those under the ages of 10 to 12, they are generally not an issue. Nonetheless, if your child is one who uses aspirin or Motrin, be certain they do not have access to these medications and do not take them two weeks before or after surgery.
Some voice change is frequent with the common cold. However, if voice changes appear and remain, they should be investigated. This will typically require a laryngoscopy. Older children may tolerate a flexible examination in the office. Younger children or those who will not tolerate the flexible exam may require a diagnostic laryngoscopy under general anesthesia. Children who spend a lot of time with a raised voice can develop irritation, polyps and nodules on the vocal chords. These are called screamers nodules. Speech and behavior therapy are generally recommended to alter the screaming habit assuming that the nodules do not resolve and the hoarseness does not dissipate, they may require surgical excision. Another cause of hoarseness much more common in children than adults is a viral illness called papilloma. These present as little fleshy growths and when present in the voice box will alter normal speech. Similar types of growths on the skin are called warts. As these have a propensity for mucosal surfaces of the upper respiratory tract to both grow and spread, early diagnosis and treatment are strongly recommended. Repeat operations both for examination and treatment may become required.
A neck mass is any lump, bump or tumor which appears in or on the neck. There are many different causes of neck masses and so careful evaluation is always required. Congenital causes of neck mass include a thyroglossal duct cyst and a branchial cleft cyst. A thyroglossal duct cyst presents as a cyst or lump in the mid line of the neck typically right at the junction of the under surface of the chin where it joins the vertical portion of the neck. The thyroglossal duct cyst will typically go up and down as the child swallows and can become infected. They all are recommended for excision. Branchial cleft cysts are also congenital in origin. They may present in young children but typically do not present until later in life. They are typically a cyst in the upper third of the neck. They too can become infected. While neither the thyroglossal duct cyst nor the branchial cleft cyst is malignant, both have the potential to be infected. Both have the potential to grow and both require excision. Both have potential for malignant degeneration. Other neck masses are typically inflammatory in origin. All children develop swollen lymph nodes during cold and upper respiratory tract infections. If these become infected with bacteria, they can form an abscess and require urgent attention. If they grow and fail to go away with resolution of the upper respiratory tract infection, appropriate consultation and consideration is recommended. Some neck masses represent tuberculosis or atypical tuberculosis in which case excision is necessary. It is always a concern that a growing neck mass may be a neoplasm and so due caution and concern is always appropriate.
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V. Facial Plastic and Reconstructive Surgery
For additional information the reader is referred to the author’s Facial Plastic Booklet.
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Protruding ears or lop ears are relatively common. If they bother the child, correction is performed. The surgery is performed via an incision behind the ear. Small pieces of skin and cartilage are excised. The ear is reshaped and sutured into a new position. The incision is closed and a dressing applied. When the dressing is removed, the child will be instructed to wear a head band for a week or two. Once healed, children do well. The surgery is usually requested around the age of 4 or 5 when other children tease the child and is a good age to perform the surgery.
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Cleft lips are typically repaired early in life. This is a difficult operation and should be performed by those with experience and a good track record. The same is true for cleft palate surgery. Nasal surgery can be performed on children of any age. Certainly, if a nose is broken, it should be reduced immediately. However, corrective operations such as septoplasty and rhinoplasty are typically deferred until the mid teens when nasal growth is complete. There are exceptions. A child with a badly traumatized nose, with a very crooked septum and with near total nasal obstruction is probably recommended for repair whenever the matter is problematic. Serious deformity which impairs social growth and acceptance may be an indication for earlier surgery. Facial trauma and fractures do occur to children. Immediate evaluation is always recommended and x-rays are often required. Some of these are repaired by closed reduction, but most displaced fractures, particularly those which cause physiologic dysfunction or disfigurement, are repaired via open surgical techniques. Children heal lacerations reasonably well. However, if unsightly scars occur, consultation for scar revision can be considered. There are a myriad of skin lesions which can occur in children, some are cosmetic and some have health implications. If your pediatrician is not certain of the diagnosis, consultation with a dermatologist or with a surgeon may be warranted. Vascular lesions such as hemangiomas will often involute and disappear in the first year of life. If they do not, they can be vaporized with a laser or in some cases excised. Black pigmented spots are called nevi. Congenital nevi often have malignant potential and consultation with a dermatologist is recommended. If the lesion has malignant potential it should be excised and the author certainly has the bias that a head and neck surgeon with training in facial plastic and reconstructive surgery should perform the surgery. Some of the nevi are benign but unsightly. If the child considers them unsightly and if friends at school ridicule and make fun of the nevi, surgery is recommended. Again, a well chosen facial plastic surgeon should be requested. Skin cancer is uncommon in children, but a word of caution, most people incur 80% of their sun damage as a child. This is a time when cells are growing. The DNA is vulnerable to ultraviolet damage. The injuries incured during sun exposure as a child are responsible for the melanoma, the epidermoid carcinoma and the basal cell carcinoma of later life. Sun avoidance and sun protection are extremely important. I make an excellent living removing the wrinkles of the aging face and resecting the skin cancer of the childhood sun worshiper and while I probably will not be in practice to care for your child’s wrinkles and skin cancers, my students will and you are well advised to be concerned about ultraviolet radiation and to protect against it.
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I have probably failed to answer all your questions and address all your concerns. Questions and constructive comments are always appreciated.
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