Differential Diagnosis in Children
Common etiologies of orbital tumors differ significantly between children and adults. For example, rhabdomyosarcoma, one of the most common primary pediatric orbital malignancies, rarely occurs in adults. A detailed knowledge of specific pediatric orbital
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Differential Diagnosis in Children Catherine J. Hwang and Julian D. Perry
Introduction There are many aspects of history, examination, and imaging that aid in the differential diagnosis of orbital lesions in children. Common etiologies of orbital tumors differ significantly between children and adults. For example, rhabdomyosarcoma, one of the most common primary pediatric orbital malignancies, rarely occurs in adults. The potential morbidity – and in some cases mortality – of pediatric orbital neoplasia requires an understanding of common findings and presentations to direct the evaluation. The history, physical examination, and diagnostic studies will help limit the differential diagnosis, which then determines the need for biopsy and initial therapy (Table 3.1).
History As with adults, the history begins with a description of the symptoms, severity, onset, and rate of progression. However, obtaining a C. J. Hwang (*) · J. D. Perry Department of Ophthalmology, Division of Orbital and Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected]
© Springer Nature Switzerland AG 2019 C. J. Hwang et al. (eds.), Clinical Ophthalmic Oncology, https://doi.org/10.1007/978-3-030-13558-4_3
detailed history in the pediatric patient presents unique challenges. The direct history depends upon the age, maturity, and verbal skills of the child. In many cases, the bulk of the history requires input from the family. The evaluator should remember that a child may deny, forget, or embellish important historical facts that can confound the evaluation of an orbital tumor. For example, a child injured with a stick or toy may not disclose the cause, or a history of otherwise insignificant periorbital trauma may obscure the workup of true orbital neoplasia. Preverbal children cannot clearly communicate subjective findings such as pain, hypesthesia, diplopia, or diminished visual acuity. In these cases, the evaluator uses nonverbal clues and physical findings to focus the examination and develop the differential diagnosis.
Presenting Symptoms and Complaints As with adults, pediatric orbital neoplasia presents with a wide spectrum of symptoms, but many may be underreported in the nonverbal child (Table 3.2). Tumor location and histology determine the presenting symptoms and signs, which can be divided into sensory, motor, and structural or functional.
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C. J. Hwang and J. D. Perry
18 Table 3.1 Classification and differential diagnosis of orbital tumors in children Developmental/ congenital
Acquired cystic Lacrimal
Inflammatory
Benign Dermoid Plexiform neurofibroma Teratoma Microphthalmos with cyst and congenital cystic eye Cranial orbital cephalocele Rathke pouch cyst Mucocele Lacrimal duct cyst Pleomorphic adenoma (rare in children) Ruptured dermoid Idiopathic lacrimal gland inflammation Idiopathic orbital inflammatory syndrome Venolymphatic malformations
Vascular
Capillary malformations Neurofibroma Optic nerve glioma Meningioma Leiomyoma Lipoma
Neural
Mesenchymal
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