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June 2004
By Brian R. Irwin, DO
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CASE:
A five-year-old Bolivian boy is evaluated during an international
medical clinic in his rural village. He, like all his fellow
villagers, has never seen a physician before. Since birth,
he has been experiencing recurrent, lingering respiratory
infections, sometimes featuring a productive cough with foul-smelling
sputum. He and other family members have recently had scabies
and are at risk for parasitic infections, which run rampant
in this locale. Physical examination reveals no rash, with
the exception of a punctate lesion near the sternal notch
that exudes purulent material when expressed. The only other
abnormalities are cervical adenopathy and a soft, subtle mass
lateral to the patient's cricoid that is mobile and moves
with swallowing. The boy's oropharynx, lungs, and nose are
unremarkable.
WHAT IS YOUR DIAGNOSIS?
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This patient had a thyroglossal duct cyst and sinus. The limited
resources of a goodwill clinic in a remote location precluded
any testing, but with a punctate skin lesion a parasitic or
worm infection was also likely, so he was treated with anthelmintics
in addition to a broad-spectrum antibiotic. He was brought to
a surgeon in La Paz who incised the fluctuant mass and discovered
a sinus tract running from the sternal notch to the underside
of the boy's tongue, which had been missed in the initial examination.
Thyroglossal cysts result from the failure of the first, second,
and sometimes third and fourth branchial clefts to fuse during
the first two months of embryonic development. Most cysts are
infected with mixed flora or gram-positive organisms. Occasionally,
tracts connect to the oropharynx, where aspiration of material
can lead to respiratory infection. |
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Dr. Irwin is a physician in private practice
at Saco River Medical Group in Conway, New Hampshire.
Emerg Med 36(6):29-30, 2004
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