Pediatric Neck Masses ,

TEF , Diaphragmatic
Hernia
Dr. Mahmoud AbuAwad
Supervised By : Dr.Mohammad Al-Omari

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Disclosures.

I have nothing to disclose.

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Contents
 Pediatric Neck Masses
 Esophageal Atresia/Tracheoesophageal Fistula.
 Congenital Diaphragmatic Hernia.
 Conclusion.
 References.

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Pediatric Neck Masses

• Have a wide range of etiologies.

• The majority are benign
• 11% of neck masses show a malignancy on biopsy.
• Etiology  Congenital, infectious, inflammatory, traumatic,
lymphovascular, or neoplastic.
• Presentation  Asymptomatic -- Acute Respiratory Distress (Size and
Location) .
• Inflammatory cervical lymphadenitis is the most common cause of
pediatric neck masses found in children.
• Congenital masses become clinically apparent when infected.
• Most common malignancy  Lymphoma.

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Pediatric Neck Masses.

 Imaging.
 Congenital 
 Branchial Anomalies.
 Thyroglossal Duct Cysts.
 Dermoid Cysts.
 Thymic Cysts.
 Infectious.
 Lymphatic Malformation ( Cystic Hygroma ).

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Imaging.

• Not always required for the diagnosis of neck masses.

• Narrowing deferential diagnosis, Helpful in clarifying  extent and size, location to
vital structures, and radiologic characteristics of a lesion.

• US is first choice  Palpable lesions such as salivary gland tumors or thyroid

nodules.
• Advantages 
• The pediatric neck often has less subcutaneous adipose tissue  better imaging
• Differentiate solid from cystic lesions,
• Color Doppler  presence and characteristics of vascular flow within a mass.
• Determining the stage of an abscess  differentiate early lymphadenopathy ( only ABx ) from a
mature abscess ( surgical drainage).
• Portable, Fast, Does not require sedation, and does not expose the pediatric patient to ionizing
radiation.
• Disadvantages 
• Variability of the technician’s skill/experience .
• Lower resolution images.
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• CT scans and MRI provide a more detailed study of the anatomy of
the neck.

• Advantages 
• CT available in emergent situations ,
• Completed quickly for patients who are critically ill.
• No need for sedation and minimal artifact from movement.
• Offering more osseous detail such as remodeling or erosion, as well as
calcifications.
• Disadvantage 
• The exposure to ionizing radiation, which could potentially have carcinogenic
effects in the long term.

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• MRI
• Advantages 
• Excellent soft tissue detail and avoidance of ionizing radiation.
• Details of the margins and possible neural spread or intracranial extension of a mass can be noted with
the use of a contrast-enhanced MRI.
• Disadvantages 
• Requires sedation due to concerns of movement artifact in the pediatric population

• Fluorodeoxyglucose PET (FDGPET)  Help with evaluating, staging, and

monitoring a solid tumor
• Advantages 
• Noninvasive tool to evaluate malignancies in children.
• Differentiate recurrent or residual tumor from changes related to treatment.
• Disadvantages 
• Expose children to ionizing radiation
• Require sedation.
• Certain tissues have a higher uptake of FDG, including the adenoids, tonsils, thymus, brown adipose
tissue, bone marrow, and the spleen.
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Congenital
(Branchial Anomalies).
• Branchial apparatus in the fetus eventually develops into head and
neck structures.
• Any deviation in the development  Anomaly ( acc. to site )
• Sinus tracts and fistulas  A younger age due
• Cysts  Get infected and enlarge.

• Modalities of Mx 
• Infection  antibiotics prior to excision (dissection and identification of
important structures easier ).
• Abscesses  needle aspiration or if needed , incision and drainage. ( be
careful for the nerves ).
• Recurrence for branchial cleft cysts  3%, if redo up to 20% .

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• Anatomy and Embryology

• The branchial arches form during the fourth to eighth week of

gestation  Four pairs of well-developed ridges with associated
clefts, Each has :
• A cartilaginous center (mesoderm),
• A cleft (ectoderm),
• An internal pouch (endoderm),
• A nerve.

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First branchial cleft anomalies :
• 8% of branchial cleft anomalies,
• Two types 
• Type 1 branchial cysts  a fistula around the conchal cartilage , The tract can
follow the course of the external auditory canal and is lined by squamous
epithelium.
• Type 2 branchial lesions  near the angle of the mandible and are composed of
both epithelium and mesoderm.
• Both can be closely associated with the facial nerve  Type 2
branchial lesions can loop under the facial nerve, pushing it laterally and
inferiorly.
• Course  The tract for a first branchial cleft usually extends from
the opening near the mandible, near the posterior aspect of the
parotid, and toward the external auditory canal.
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Second branchial cleft anomaly
• M.C , 90% of branchial cleft anomalies.
• Isolated cyst or as a sinus tract/fistula that extends from the cervical
skin to the tonsillar fossa.

• Presentation  Enlarging, tender mass ( at the time of an upper

respiratory tract infection )
• Fistula : will course through the internal and external carotid arteries, over
the hypoglossal and glossopharyngeal nerves to end in the tonsillar fossa.
• Cyst : anywhere along this tract, but most commonly occurs in the anterior
triangle of the neck below the hyoid.

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Third branchial cleft Anomaly
• Rare.
• Presentation 
• cysts low and anterior in the neck.
• Fistulas can course from the piriform fossa and drain to the anterior cervical
skin ( pierces the thyrohyoid membrane and tracks under the
glossopharyngeal nerve and internal carotid artery, but stays above the vagus
nerve).
• These lesions can be intimately involved with the thyroid, and
sometimes a hemithyroidectomy is required for repeated
recurrences.
• An infected TGDC or third branchial cleft cyst may be the cause of
suppurative thyroiditis in children.

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Fourth branchial cleft Anomaly
• Extremely rare.
• The external location for a fourth branchial cleft is the same as the
second and third, but the internal opening is near the apex of the
piriform sinus.

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Treatment
• The standard treatment for all types of branchial anomalies is
complete surgical excision.
• Under GA
• Position  supine with neck slightly extended with a shoulder roll.
• sinus tract or fistula present  a small ellipse is made around this
opening , cannulation with a small lacrimal probe with methylene
blue .
• The tract is then dissected cephalad until the end of the sinus tract or
until the internal opening of the fistula is reached.

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• For Second Branchial cleft Anomalies :
• The tract is then ligated with absorbable suture. Often a direct laryngoscopy
or simply a finger placed in the oropharynx can help to visualize the course of
the tract and assist with dissection.
• Some patients might require a “stepladder” incision to trace the tract
superiorly

• For Third and fourth branchial Anomalies :

• Dissections are similar to a second branchial cleft.
• Endoscopy at the beginning of the case can greatly assist in locating and
resecting the tract.
• One promising surgical option for third or fourth sinus tracts is cauterization
or sclerotherapy.

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• For Cartilaginous remnants : ( rarely get infected , removal for
cosmetic indications) are normally small and present in the
subcutaneous tissue along the anterior border of the
sternocleidomastoid, are usually palpable and easily resected.

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Preauricular cysts, pits, and sinuses
• Common ,
• From the first two branchial arches.
• bilateral in comparison to first branchial cleft cysts.
• Rarely become infected.
• The tracts extend from the skin down to the helical cartilage of the
auricle and are lined with squamous epithelium.
• Treatment is surgical excision
• Recurrence  19% to 40%.

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Thyroglossal Duct Cysts

• Congenital 
• Thyroglossal duct tract that occurs during the descent of the thyroid.
• The thyroid descends from the foramen cecum at the sixth week of gestation
• Tracts along the anterior neck in close association with the developing hyoid bone.
( involutes , but if it persists  TGDC at any point from the foramen cecum to the thyroid

• TGDCs  M.C neck mass besides benign lymphadenopathy in the pediatric

population.

• Presentation  A midline neck mass that may move with protrusion of the
tongue.
• Imaging 
• US ( characteristics of the cyst ),
• determine if there is a normal thyroid gland present.

Rarely, TGDC could be the sole functioning thyroid tissue in the patient.
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• Treatment  Surgical excision and removing the entire tract with a
core of tissue and the central
• Portion of the hyoid bone ( minimize recurrence).
• Complete excision ( curative )
• Recurrence  less than 10%

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• Under GA .
• Postion  Supine , the neck extended and placement of a shoulder
roll.
• A horizontal skin incision is made over the cyst, with no need to
excise skin unless a fistulous tract or infection has involved the
dermis.

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• Careful dissection around the cyst then allows continued dissection
superiorly toward the hyoid bone.
• Muscular attachments to the central hyoid bone are removed with
cautery and the hyoid is removed en bloc with the cyst and tract.
• A core of tissue is then removed above the hyoid bone toward the
base of tongue.

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• The tract is then ligated with absorbable suture.
• Placing a gloved finger at the base of tongue can sometimes facilitate
this maneuver
• The wound should then be irrigated copiously and closed in a layered
fashion.
• A drain is often used.

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Dermoid Cysts

• Considered in the differential of any midline lesion,

• Dermoid cysts contain tissue from the three germinal layers, which
can include sweat glands and sebaceous glands.
• Considered as Entrapped epithelium at the time of embryonic fusion.
( Midline ).
• On examination  firm masses that are soft, mobile, nontender, and
grow slowly.
• Nasal Dermoid  penetrate the bone ( CT or MRI should be
performed to rule out intracranial extension) .
• Treatment  Total surgical excision.

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Thymic Cysts

• Lesions of the thymus usually occur in the lower neck, but

can present anywhere from the piriform sinus to the chest.

• The Differential includes 

• Thymic cysts,
• Thymic hyperplasia,
• Thymoma

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Infectious

• Benign Cervical Adenopathy  The most common cause of a neck

mass in the pediatric population.
• Cervical lymph nodes are palpable on examination ( 40% of infants ,
55% of pediatric patients ).
• Normal L.N  less than 1 cm in size , asymptomatic , Age less than
12 years of age.

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• Lymphadenitis 
• M.C in the submandibular region and cervical nodes,
• Sources 
• Viral, Bacterial  upper respiratory infections are the most common cause
of cervical lymphadenopathy,
• Fungal ( Immunocompromised )
• Neoplastic.
• Cat scratch disease,
• Mononucleosis,
• Atypical mycobacterium,
• Tuberculosis

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• Acute suppurative lymphadenitis  M.C in the 6-month to 3-year
range, with lymph node enlargement associated with an upper
respiratory tract infection.
• Etiologies  Staphylococcus aureus and group A beta-hemolytic
streptococci.
• Presentation  Overlying skin changes with erythema and cellulitis,
with an associated leukocytosis and fever.
• The lymph node enlarges and eventually outgrows the blood supply,
resulting in central necrosis.

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• Management 
• Needle aspiration of purulence, but often requires an incision and drainage
with placement of a drain or packing under anesthesia. ( care of near vital
structures).
• Antibiotics are geared toward Staphylococcus and Streptococcus but cultures
should be taken with a change in antibiotic therapy if necessary.
• Excisional biopsies  If L.N > 2 cm , > 8 weeks, immobile or rapidly growth
( cultures, histopathology, and flow cytometry).

• Prognosis  Induartion ( several weeks to resolve ) ,

• Recurrence is rare ( Anomaly ).

• Chronic or Subacute Lymphadenitis  Enlargement of lymph nodes

( solitary, nontender, mobile ), Not associated with an acute infection
Associated with URIs, tonsillitis, otitis media, or allergic rhinitis.
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Lymphatic Malformation ( Cystic Hygroma )

• Slow-flow vascular anomalies

• 75% of LMs present in the head and neck.
• Incidence  1 in 2,000 to 4,000 births
• Age  first decade of life.
• Etiology 
• The lymphatic system develops around week 5 of gestation .
• Failuire of lymphatic system to establish connections with the main lymphatic system
or venous channels.
• Histopathology  progressive dilation of abnormal vessels and LMs are
composed of vascular spaces filled with eosinophilic and protein-rich fluid.
• Presentation  not apparent until enlargement due to infection or trauma
with hemorrhage.
• Diagnosis  prenatal US, and can potentially obstruct the airway and may
require an ex utero intrapartum treatment procedure (EXIT procedure).

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• Types
• Microcystic 
• Above the mylohyoid and can involve the floor of mouth, tongue, parotid,
and lip .
• Poorly defined borders and infiltrate nearby muscle and fatty planes
• Macrocystic
• below the mylohyoid and have multiple large,
• loculated cysts in varying size and shape ( infection or trauma, which can
lead to airway obstruction, functional issues (swallowing, speech), or
deformity
• Mixed lesions.

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• Treatment 
• Observation, sclerotherapy, or surgery.
• Macrocystic  Amenable to both sclerotherapy and surgical excision,
• Microcystic  Exision would often result in unacceptable morbidity
(infiltrative nature).
• Subtotal resection  high recurrence rate , Difficult surgery
( previous inflammation and scarring from sclerotherapy) .
• Radiofrequency ablation  relief of ulceration tongue lesions or oral
mucosa.
• The CO2 laser  symptomatic lesions of the airway or oral cavity,
( reduce bleeding and ulceration).
• Rapamycin or “sirolimus”  possible oral medication

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Esophageal Atresia/Tracheoesophageal
Fistula.

 Embryology.
 Classification.
 Incidence and epidemiology.
 Clinical Findings, Diagnosis, and Pathophysiology.
 Associated Anomalies.
 Preoperative Management.
 Surgical Technique.
 Results, Complications, and Outcomes.

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Esophageal Atresia/Tracheoesophageal
Fistula.

Embryology
• Respiratory system 
• Develops from the laryngotracheal groove on the ventral foregut
( gestational weeks 3 and 4 ).
• The groove develops into a diverticulum (outpouching) and
elongates to form the laryngotracheal tube.
• The developing respiratory system is partitioned off from the
esophagus by the tracheoesophageal septum.
• The proximal end of this tube becomes the larynx, the middle
becomes the trachea, and the distal end forms the lung buds.

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 • Classification

The anatomy of the variants of esophageal atresia and tracheoesophageal fistula (TEF).
A: Proximal pouch with distal TEF (most common type occurring in 85% of patients; Gross type “C”).
B: Esophageal atresia without TEF (5%).
C: TEF without esophageal atresia (<5%).
D: Esophageal atresia with proximal and distal TEF (rare).
E: Proximal TEF and distal pouch(rare).

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 Incidences and Epidemiology
• 1:2, 500 to 1:4, 500 live births.
•M>F
• Chromosomal anomalies, congenital heart disease, and other
anomalies are more common than expected.

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Clinical Findings, Diagnosis, and Pathophysiology
• Diagnosis 
• History of choking with feeding , confirmed by the inability to pass an
NG tube into the stomach, Excessive drooling
• Past History of Maternal polyhydramnios should raise suspicion for
the diagnosis.
• Early (Risk of respiratory distress and aspiration).
• Confirmation 
• Radiograph identifying a tube in a proximal pouch in most cases,
• Injection of air to outline the pouch will be necessary for confirmation .
• Presence of a scaphoid abdomen with no intragastric on radiograph taken
several hours after birth confirms the diagnosis of pure esophageal atresia.

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• Reflux of gastric contents through the fistula can enter the lungs 
respiratory compromise
• In case of severe respiratory distress, gastrostomy or gastrostomy
plus division of fistula become an emergency procedure.

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Associated Anomalies
• Present in approximately one-half of the neonates with esophageal
atresia.
• Cardiovascular defects which occur in 17% to 50% of infants. ( M.C )
• Genitourinary,
• Other gastrointestinal,
• Skeletal neurologic,
• Craniofacial defects.

• The occurrence of vertebral anomalies, anorectal malformations,

cardiac, tracheoesophageal renal, and limb (usually radial) anomalies is
known as the VACTERL association.
• Two or more of the defects must occur to be denoted as VACTERL and
this occurs in 10% to 21% of cases.
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Preoperative Management
• NPO
• Sump tube is placed in the upper esophageal pouch.
• Head-up position ( Decrease reflux via the fistula into the lung).
• Intubation is avoided as it increases the risk of reflux into the lungs via the
fistula.
• Ventilatory support ( low birth weight or prematurity ).
• Preoperative antibiotics
• Emergent bedside gastric decompression may be necessary before definitive
surgery ( not improve ventilation, emergency operative ligation or placing an
occluding distal esophageal balloon may allow for ventilation) .
• Chest radiograph, echocardiograpy ( Evalute The side of the aortic arch, major
cardiac anomalies  a right-sided arch, the operative approach is modified).
• Radiographs of the spine are also commonly performed.
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• Outcome  Waterston Criteria ( birthweight, pneumonia, and
associated anomalies. With improvements in neonatal critical care ) ,
revised with Spitz classification :
• a 1,500 g weight as the cutoff,
• with or without major cardiac disease.
• Currently survival for greater than 1,500 g infants without cardiac
disease is approximately 97%,
• survival for either cardiac disease or less than 1,500 g approaches
82%
• Both birth weight less than 1,500 g and cardiac anomaly survival is
approximately 50%.

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 Surgical Technique.
• The extrapleural plane is established at the fourth intercostal space and
developed sufficiently to allow control of the fistula and mobilization of
the proximal pouch.
• Initially, the fistula is divided and ligated followed by mobilization of the
proximal pouch.
• Anastomosis is performed in a single layer with an absorbable suture,
more recently using a monofilament.
• If needed there are various techniques for elongation and the esophagus
may be mobilized both proximally and distally.
• Myotomies on the upper pouch, either circular or spiral and flap
tubularization have been described.
• A transesophageal tube is often passed during the case and can be utilized
for feeding prior to performance of a postoperative esophagogram.
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• High-risk infants ( Severe respiratory failure (usually from
prematurity) and structural heart disease )  delayed repair.
• A decompressive gastrostomy, proximal pouch suctioning, and
parenteral nutrition are used until the infant is ready for operation.
• A staged repair that employs gastrostomy, surgical division of the
tracheoesophageal fistula, followed by esophageal anastomosis as a
second thoracic operation is rarely used except as a lifesaving
approach.
• Tracheoesophageal fistula with esophageal atresia  H-type fistula.
• Repair is performed via a cervical approach after bronchoscopically stenting
the fistula with a small catheter.
• The catheter aids in dissection and care must be taken to stay in the plane of
the esophagus.

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Complications,
• Injury to the vagus nerves, recurrent laryngeal nerves, posterior trachea, and
adjacent vessels.
• Anastomotic leak occurs in approximately 10% to 20% of cases and most may
be treated nonoperatively.
• The presence of a leak prolongs hospitalization the retropleural tube is left in
place, the infant is not fed, and antibiotics are administered.
• Esophageal stricture is seen in up to 40% of infants after repair.
• Recurrent tracheoesophageal stricture is reported in up to 10% of patients.
• Gastroesophageal reflux is present in nearly all patients with esophageal
atresia.
• Esophageal dysmotility is present in the majority or patients and may be
responsible for dysphagia and recurrent respiratory problems.
• Tracheomalacia occurs in approximately 10% of patients and may be diagnosed
after the repair of esophageal atresia.
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Outcomes
• Mortality  high for infants with severe congenital heart defects and
chromosomal anomalies.
• Late deaths may occur related to respiratory disease (tracheomalacia,
reactive airway disease, gastroesophageal reflux, and aspiration).
• Adult survivors of esophageal atresia repair have a normal quality of
life with the exception of morbidity from esophageal, functional, and
respiratory disorders.
• The very long-term effects are unknown but Barrett esophagus and
esophagitis have been reported

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Congenital Diaphragmatic Hernia.

 Embryology of the Diaphragm.

 Pathology and Pathophysiology.
 Diagnosis.
 Prognostic Factors.
 Treatment.
 Surgery.
 Outcome.
 Evolving Therapies.
 Foramen of Morgagni Hernia.
 Eventration of The Diaphragm.

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Embryology of the Diaphragm
• The diaphragm develops more superiorly than its postnatal
location but maintains its innervation from cervical roots C3,
C4, and C5.
• It is formed from four embryologic structures that fuse by
week 7 :
■ The septum transversum is formed by mesodermal tissue that
projects from the ventral body wall to partially separate the thoracic
cavity and abdominal cavity. In the adult, the septum transversum
forms the central tendon of the diaphragm.
■ The pleuroperitoneal folds extend from the dorsolateral sides of the
body wall to form the pleuroperitoneal membranes, which then fuse
with the septum transversum.

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 The body wall also extends from the dorsal and lateral sides (after
the pleuroperitoneal folds have closed the thoracic cavity) to form
the peripheral, muscular portion of the adult diaphragm.
■ The dorsal mesentery of the esophagus forms the portion that is
dorsal to the esophagus and ventral to the aorta.

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• Pathology and Pathophysiology
• 1:3,000 to 2:4,000 live births.
• Most of the deaths  other fatal anomalies.
• Defects are more common on the left side
• The cause of CDH is unknown ( combination of intrinsic
predisposition (genetic factors) and environmental factors (teratogen
or deficiency) )  abnormal diaphragm and lung development.

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• During the early development of the diaphragm, the midgut is largely
extracoelomic.
• Failure of closure of pleuroperitoneal canal  the abdominal viscera
herniate through the lumbocostal trigone into the ipsilateral thoracic cavity.
 prevents its normal counterclockwise rotation and fixation.

• The small bowel, other intraabdominal organs such as the spleen,

stomach, colon, and liver may also herniate through the
diaphragmatic defect.

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• Left-sided CDH is characterized by a 2- to 4-cm posterolateral defect
in the diaphragm through which the abdominal viscera have
translocated into the ipsilateral thoracic cavity.
• On a right-sided defect, the large right lobe of the liver can occupy
most of the hemithorax, The hepatic veins may drain ectopically into
the right atrium, and the liver and lung may be fused.
• Pulmonary parenchymal compression by the herniated organs 
growth and maturation of the lung.

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Diagnosis
• Prenatal ultrasound examination (66%) .
• Polyhydramnios is common.
• Prenatal MRI is utilized for more accurate delineation of the defect.
• Presentation  cyanosis and respiratory distress shortly after birth in
severely affected neonates.
• On physical examination  scaphoid abdomen.

• A plain chest radiograph with loops of intestine in the chest confirms

the diagnosis of CDH with an NG tube in place to confirm the position
of the stomach

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• Echocardiography ( Evaluate for degree of pulmonary
hypertension and to determine presence of cardiac defects).
• Differential diagnosis 
• Eventration of the diaphragm,
• Anterior diaphragmatic hernia (Morgagni),
• Congenital pulmonary malformations,
• Unilateral pulmonary effusion, and primary agenesis of
the lung.

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 Prognostic Factors
• The lung to head ratio (LHR)  by multiplying the simultaneous
sonographic measurements of the size if the contralateral lung in an
anteroposterior and lateromedial direction, and dividing by the head
circumference.
• Ratios less than 1 have been associated with poor outcome.
• Liver above the diaphragm has also been used to determine outcome with
decreased survival with liver-up.
• The combination of a low LHR with liver-up has a poor outcome.
• The size of the defect was a significant factor in survival,
• A major cardiac anomaly and 1-minute Apgar sores of ≤4 were associated
with increased mortality.

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Treatment
• Referral to an appropriate tertiary care perinatal center with the
availability of the full array of respiratory care strategies.
• Resuscitation with standard neonatal resuscitation guidelines
• Endotracheal intubation and nasogastric tube insertion.
• Careful management of temperature regulation, glucose
homeostasis, and volume status should be performed.
• Fluid resuscitation should be performed with crystalloid, blood
products, and colloid.
• Inotropes such as dopamine or dobutamine are utilized if needed.
• ventilatory methods,
• ECMO (when ventilator therapy has failed) .
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Surgery
• Semielective
• Repair 
• subcostal incision or thoracotomy incision. Both
thoracoscopic and laparoscopic.
• The abdominal organs are returned to the abdomen.
• The defect in the diaphragm is repaired.
• Primary repair with nonabsorbale suture is preferred.
• If the defect cannot be repaired primarily due to size, a
prosthetic patch such as Goretex has been utilized.

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Outcome

• Survival rates ( 65% to 78% ) prev  50%

• Morbidities  long-term use of bronchodilators, need for
gastrostomy for nutritional support, and increased rate of GERD
requiring surgery.
• Higher incidence of GERD, recurrent intestinal obstruction, and
recurrent abdominal pain.

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Foramen of Morgagni Hernia
• The anterior CDH  rare ( 3% to 5% of all CDHs).
• Diagnosed during childhood.
• By chest or abdominal radiographs being performed for presumed
pneumonia or gastrointestinal symptoms
• This is an anteromedial hernia at the junction of the septum transversum
and the thoracic wall with contents being seen in a retrosternal position.
• There is a hernia sac present and the sac may contain colon, small intestine,
or liver.
• The hernias are repaired due to the risk of segmental intestinal volvulus or
obstruction.
• Repair may be performed through a laparoscopic approach. The sac is
excised and the diaphragm is sutured to the undersurface of the posterior
rectus sheath at the costal margin.
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Eventration of the Diaphragm
• Diagnosed  The abnormal elevation of one or both
hemidiaphragms .
• Two Types  congenital ( Infection ).
• Acquired injury to the phrenic nerve.
• Surgery  symptomatic cases after several months of observation
• The surgical management is with plication of the diaphragm with
nonabsorbale sutures.

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Conclusion.

• Infants are obligate nasal breathers for the first 3 to 6 months of life;
therefore, any nasal obstruction can cause respiratory distress.
• The site of the neck mass is important (midline vs. lateral) for
narrowing the differential diagnoses.
• Benign cervical lymphadenopathy is the most common neck mass in
the pediatric population.
• Although rare, always consider malignancy to avoid delay in
diagnosis.
• History is important in the work up and treatment of an airway
foreign body

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Conclusion.

• Tracheoesophageal fistula can occur as esophageal atresia with

proximal pouch and distal tracheoesophageal fistula (most common,
at 85% to 95%), esophageal atresia without fistula (5% to 7%),
tracheoesophageal fistula without esophageal atresia H type (2% to
6%), and rarer forms of this anomaly including esophageal atresia
with proximal tracheoesophageal fistula and esophageal atresia with
both proximal and distal tracheoesophageal fistula.
• Congenital diaphragmatic hernia (CDH) is a physiologic emergency
and not a surgical emergency. The newborn with CDH should be
stabilized by nonsurgical means and delayed, well-planned surgical
repair undertaken subsequently.

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References.

• Greenfield’s Surgery Scientific Principles & Practice , SIXTH EDITION.

• P. Puri · M. E. Hِllwarth (Eds.) Pediatric Surgery.
• Congenital swellings of the head and neck , Gerard PS Siou , Oxford.
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• THANK YOU

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