Officers for 2021-2023
Tricia Swan, M.D., M.Ed, FACEP, FAAP
Dr. Swan is pleased to be able to serve as your Chair of the Pediatric Emergency Medicine Section for the next 2 years! A little background on her, she completed her medical degree at the University of Oklahoma. Her residency training was in Pediatrics at the University of Florida-Jacksonville and then she went on to complete her fellowship training in Pediatric Emergency Medicine at The Children’s Mercy Hospital in Kansas City, Missouri. Dr. Swan has 12 years of experience as a clinician, educator, administrator and mentor. Currently, she is an associate professor of Pediatric Emergency Medicine in the Department of Emergency Medicine at the University of Florida in Gainesville. In 2021, she became the Program Director for the Pediatric Emergency Medicine Fellowship.
Section Officers 2021-2023
Chair: Tricia Swan
Chair-elect: Cristina Zeretzke-Bien
Outgoing Chair: Taryn Taylor
Secretary: Jennifer Sanders
Councillor: Jason Lowe
Alternate Councillor: Shobhit Jain
Microsite Co-editor: John Misdary
Microsite Co-editor: Yagnaram Ravichandran
Microsite Co-editor: Jaryd Zummer
Pediatric Emergency Medicine Section members may send an e-mail to the Pediatric EM Section Microsite Team via firstname.lastname@example.org.
Pediatric Emergency Department, Department of Emergency Medicine, Harbor-UCLA Medical Center
Case Presentation: Tongue Depressor
A 5-year-old male presented to the pediatric ED due to a growth on the tip of his tongue. The patient’s mother was worried as the mass had been increasing in size and was bleeding, causing decreased oral intake. Further history revealed progressive tongue swelling and increasing growth of the mass over a three-month period. Upon further questioning, it was presumed that the mass formed after a traumatic injury where he bit his tongue. Prior to this visit he presented to three other EDs and was unable to receive a referral to Otolaryngology due to insurance issues.
On examination, the apex of the tongue appeared to have a 5 cm, multilobular mass with irregular borders and friable areas of bleeding and evidence of necrosis.
MRI was obtained to characterize the mass and revealed a solid-appearing, well-circumscribed and enhancing vascular lesion measuring approximately 1.1 x 2.0cm arising from the tip of the tongue without associated cervical lymphadenopathy.
Pyogenic granuloma (PG) is a cause of oral cavity soft tissue swelling that likely results from irritation or trauma initiating an excessive tissue repair response.1 Types of trauma or irritation could be from a sharp cracked tooth edge, poor brushing technique, or biting the tip of the tongue, as in our case. PG most commonly occurs on the gingiva.1,2,3 Extragingival sites include the tongue, lip, buccal mucosa, hard palate, and the floor of the mouth. For most PG, the size of the lesion ranges between 0.5cm and 2cm, and they may grow at an alarming rate within days.4 A PG mass may have a pedunculated or sessile base and is usually nontender, is prone to bleeding.2
The differential diagnosis of oral PGs include hemangioma, lymphangioma, peripheral giant cell granuloma, peripheral ossifying fibroma, conventional granulation tissue, malignancy, Kaposi’s sarcoma, syphilis, and tubercular or traumatic ulcer.5 PG is managed by surgical excision and curettage of the adjacent area with topical timolol in small children.1 It has a strong tendency to recur (up to 15%) after simple excision if the associated irritant is not removed (ex. broken tooth edge, plaque or calculus).5
University of Pittsburgh Medical Center
A 13-year-old-female with a past medical history of Crohn’s disease, presented to the Pediatric Emergency Department (PED) with 8 hours of headache, left eye pain and periorbital swelling. She denied trauma or fevers.
Exam demonstrated left periorbital swelling with ecchymosis and tenderness to palpation. Swelling prevented assessment. Intra-ocular pressure (IOP) was unobtainable.
Emergent ophthalmology consult was obtained and a lateral canthotomy with cantholysis was performed in the PED. CT of the orbits showed left periorbital swelling with diffuse enlargement of the recti muscles. Diagnosis was determined to be most consistent with orbital compartment syndrome (OCS) secondary to orbital inflammatory pseudotumor (OIP) as a complication of IBD.
Lateral canthotomy with cantholysis is a rare1, yet critical vision-preserving procedure. Reports detailing its use in PEDs are quite infrequent2,3. The primary indication for lateral canthotomy, OCS, is most often caused by orbital or ocular trauma, surgical complication, or retrobulbar fluid collection precipitating an acute rise in intra-orbital pressure. OIP is an exceedingly uncommon etiology of OCS4. OIP typically manifests as a chronic process, is treated with corticosteroids, and is associated with systemic inflammation, post upper respiratory infection, viral, or strep infection5, and various rheumatologic and autoimmune conditions. OCS identification is a critical skill, and despite the paucity of literature regarding its use in the pediatric emergency setting, lateral canthotomy should be considered an essential part of pediatric emergency medicine training.
1 Soare S, Foletti JM, Gallucci A, Collet C, Guyot L, Chossegros C. Update on orbital decompression as emergency treatment of traumatic blindness. Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery. 2015;43(7):1000-1003.
2 Hamill EB, Weber AC, Patel KR, Yen MT. Bilateral Orbital Compartment Syndrome Preceding Cerebellar Herniation in Neuropsychiatric Systemic Lupus Erythematosus. Ophthalmic plastic and reconstructive surgery. 2019;35(3):e55-e57.
3 Malla G, Bhandari R, Gupta PP, Giri R. Penetrating orbit injury: challenge to emergency medicine. BMC research notes. 2013;6:493.
4 Tiong KI, Aziz S, Hazlita I. Orbital compartment syndrome in idiopathic orbital inflammatory disease: A case report. The Medical journal of Malaysia. 2015;70(5):316-317.
5 Rabina G, Leibovitch I, Abumanhal M, Rosenblatt A, Ben Cnaan R. Orbital Inflammatory Syndrome Post Group A Streptococcal Infection – Case Series and Review of Literature. Ocular immunology and inflammation. 2019;27(1):162-167.