Pediatric ingrown toenail

Description of the disease: Usually the nail spike, proud flesh, and inflammation formed at the edge of the big toe’s nail causes the complaints. It most often develops in adolescence: it can be caused by improper nail cutting, sweating, not sufficiently thorough foot hygiene.

Symptoms: Swelling, redness, pain, discharge, or purulence beside the affected toenail.

Treatment options: Conservative treatment: careful foot hygiene, changing socks and shoes often during the day. Proper nail cutting technique. Disinfection is used in case of inflammation. Pedicure: nail correction by a pedicurist. Surgery: excision of the ingrown nail edge, removal of proud flesh and granulation tissue. It can usually be performed under conduction anesthesia, and general anesthesia may be considered for younger children.

Penile adhesion

Description of the disease: The foreskin that normally covers the glans is attached to the glans with a thin cellular membrane layer. This is age specific and not abnormal.

Symptoms: The foreskin cannot be or only partially can be retracted. Yellowish, “cottage cheese-like” material can accumulate under the internal layer of the foreskin.

Treatment: Apart from careful hygiene and pulling the foreskin back and forth after the spontaneous dissolution, there is nothing else to do. If other urethral malformations are suspected, dissolution (adhesiolysis) may be considered for differential diagnostic reasons. This disorder is normal in this age; therefore, it does not require medical or surgical care!

Foreskin inflammation

Description of the disease: A bacterial, purulent inflammatory process in the foreskin.

Symptoms: Painful urination or even urinary retention. The foreskin is swollen, red, and cannot be pulled due to the swelling. Stinky pus may be excreted from under the foreskin.

Treatment: Rinsing the pus with a no-sting disinfectant solution (e.g., diluted Betadine solution).

Phimosis

Description of the disease: Circular narrowing of the foreskin usually due to chronic inflammation.

Symptoms: The foreskin is scarred, tight and can be barely or not at all retracted. The foreskin may swell when urinating, which is a sign of a urinary obstruction.

Treatment: In milder cases, conservative treatment may be sufficient: exercise, topical steroid cream treatment. In case of failure or in severe cases, circumcision is recommended under general anesthesia. Other “half-circumcisions” and plastic surgery solutions are not recommended due to poor cosmetic results.

Epigastric hernias

Description of the disease: Pre-peritoneal fat bulges out in the midline of the abdominal wall due to the lack of continuity of linea alba.

Symptoms: In the midline of the abdominal wall, anywhere between the sternum and the navel, there is a palpable, pea-to-bean size, subcutaneous, minimally movable soft tissue deviation that cannot be replaced behind the hernia gate.

Treatment: Surgical closure is recommended under general anesthesia.

Umbilical hernia

Description of the disease: In most children up to 3 to 4 years of age, the navel ring is open in some extent. If the hernia gate is so wide that the omentum or a gut segment can protrude through it, we are talking about an umbilical hernia.

Symptoms: Upon intaabdominal pressure increase, hernia content (intestine, omentum) protrudes in the umbilical ring. The hernia can be easily replaced.

Treatment:  No treatment is needed under 4 years of age. Adhesive patch use that was recommended earlier, has no sense. Over the age of 4, especially if the hernia causes complaints, it requires surgical care. Under anesthesia, the hernia gate is closed from a small incision near the navel.

Swellings in the groin area
Inguinal hernia

Description of the disease: The inguinal ring is open, and when the abdominal pressure increases, hernia content (omentum, intestinal loop, ovaries in girls) protrudes through it.

Symptoms: Hernia can be palpated in the groin are or possibly in the scrotum. In case of intestine, gurgling can be felt during the replacement of the hernia. In boys, it is important to examine the position of the testicles.

Treatment: Inguinal hernia is an absolute surgical indication. Surgery should be performed over the age of 1 year if possible, but the child should be at least 6 months old. The closure of hernia may be performed by laparoscopy (abdominal keyhole surgery) or by the traditional open procedure.

Hydrocele

Description of the disease: there are 3 types of hydrocele:

• Funicular hydrocele/water hernia along the spermatic cord: A fluid containing cyst develops in the groin area.
• Communicating hydrocele: A lesion equal to the inguinal hernia, but with a narrower passage so only fluid can travel through it.
• Testicular hydrocele/closed testicular water hernia: Water hernia around the testis that does not substantially change its size.

Symptoms: In closed and funicular hydrocele, fluid can be palpated around the testis or in the groin area. In case of a communicating hydrocele, fluid is usually seen around the testicles in the evening and disappears by morning. In case of an illness (common cold, diarrhea), the amount of fluid may increase.

Treatment: Closed-type hydroceles usually disappear by themselves by 2 to 4 years of age, therefore surgery is not warranted until this age. Communicating hydrocele may close up approximately until the age of 2. If they do not heal on their own, surgical care is warranted. Closed hydroceles are operated from an inguinal approach, while communicating hydroceles can be operated laparoscopically.

Undescended testicle

Description of the disease: The testicles normally develop in the same place with kidneys during fetal life. The kidneys go up and the testicles go down. The descending of the testicles may be disturbed anywhere, it can “get stuck” in the abdominal cavity itself or in the groin area, or it can follow a completely wrong descending route.

Symptoms and treatments:

• if the testicle is not palpable: abdominal ultrasound or laparoscopic exploration is indicated. If no testicle is found by laparoscopy, testicular aplasia (not developed testicle or absorbed testicle) can be diagnosed. If the testicle is atrophied or damaged, it needs to be removed. If the size of the testicle is acceptable and it cannot be transferred to the groin area, a 2-step surgery (e.g., Shehata’s procedure) is indicated. If it can be pulled down to the groin area, it is recommended to pull it into the scrotum in one step.
• if the testicle is palpable: if the testicle is palpable in the groin area, it needs to be pulled down from an inguinal approach and fixed in the scrotum (traditional Shomaker’s surgery).
• in case of retractile testicle: the testicle moves between the scrotum and the groin area due to the vivid cremaster reflex. Spontaneous cessation is expected with age and it does not require treatment.

It is important that non-descending testicles are much more likely to be a source of malignancy later on as compared to the normal population! Surgery for undescended testicles is indicated around the age of 6 to 12 months.

Moles

Description of the disease: Hyperpigmented skin lesions.

Symptoms: The lesions are darker than the surrounding skin, possibly with irregular edges and hair.

Treatment: Excision under local anesthesia or general anesthesia if dermatologically indicated. Histological examination is mandatory!

Benign soft tissue lesions

Description of the disease: Benign overgrowth of the skin and appendages. In childhood, these are most often seen as a pendulum in front of the ear or atheroma.

Symptoms: Swelling of a different quality from the surrounding soft tissues, which can be inflamed and painful.

Treatment: Excision under local anesthesia or general anesthesia if dermatologically indicated. Histological examination is mandatory!

Pilonidal sinus

Description of the disease: Fistula or cyst above the sacrum. The tendency is increased in case of excess weight, thick body hair, and sedentary lifestyle. The hairs above the sacrum are sunken, and due to the vacuum effect, the hairs get into the soft areas under the skin. Here, it causes a foreign body reaction leading to the development of a cyst, possibly an abscess, and then a fistula.

Symptoms: A fistula opening above the sacrum with hairs inside. In case of an abscess, redness, swelling, fluctuation and severe pain are observed.

Treatment: Careful hygiene and hair removal are essential. In case of abscess, it needs to be explored under general anesthesia or local anesthesia. In case of a fistula or cyst, several surgical procedures are feasible (under general anesthesia):

• excision, open treatment
• excision, primary closure
• endoscopic surgery (PEPSiT) – introduced in Hungary in 2019 by the pediatric surgeon practicing in Emineo Private Hospital.

Cervical cysts and fistulas

Description of the disease: Passages that were not closed during fetal development remain in the midline or side of the neck and produce secretions.

Symptoms: In case of medial, i.e. midline cervical cyst, a swelling filled with fluid develops at the level of the epiglottis under the skin. In case of a lateral cervical fistula, secretion is excreted through a small opening on one side of the neck. Infection and inflammation may develop in both cases.

Treatment: In case of inflammation, local antiseptic treatment, possibly antibiotic therapy. In case of an abscess, exploration under general anesthesia. It is advisable to remove it in a planned, non-inflammatory period at the age of 1-3 years. Inflammation and recurrence may occur. If the lesion is not removed surgically, abscess and cancerous degeneration may occur later in adulthood.

Short lingual frenulum

Description of the disease: The lingual frenulum is short; therefore, the tongue cannot be sufficiently raised.

Symptoms: In newborns and infants, suckling is insufficient, and the child does not develop at a proper pace. The baby gets tired during breastfeeding and does not consume the necessary doses of milk. Later, the speech therapist notices that the short tongue brake prevents the proper pronunciation of certain sounds (e.g., “R”).

Treatment: In neonatal age, the frenulum is cut with scissors without any anesthesia – as there are no blood vessels or nerves in the thin membrane. In preschool age, if requested by a speech therapist, the frenulum is cut during a short general anesthesia with an electric scalpel.

Belly button discharge

Description of the disease: Discharge in the newborn or infant after the umbilical cord stump has dried up and fell off.

Symptoms: Most often, small proud flesh develops due to chronic irritation (“belly button mushroom” – because of its shape). Rarely, there may be a developmental abnormality in the background when the urinary tract, rarely a section of the small intestine, communicates with the navel, therefore urine/feces may be excreted here (in case of urinary tract, it is called urachus fistula and in case of small intestine, it is called Vitelline duct).

Treatment: It is sufficient to keep the discharging navel clean and use disinfection. Rarely, caustic pencil use may be also indicated. If there is a developmental disorder of the small intestine or urinary tract, surgical treatment is indicated.

Trigger finger

Description of the disease: Thickening of the flexor tendon sheath with inability to stretch the fingers of the hand.

Symptoms: A soft swelling on the fingers of the hand, most often on the palm side of the thumb at the base of the finger, and the finger cannot be extended.

Treatment: A small excision at the base of the affected finger, a longitudinal incision of the tendon sheath under general anesthesia.

Polydactyly

Description of the disease, symptoms: Presence of finger(s) beyond the normal number of fingers of the hand.

Treatment: In addition to the physical examination, an X-ray should be taken after the age of 1 year in order to learn about the exact bone structure of the fingers. This way, the removal of the extra finger can be carefully planned. If only a small rudimental finger hanging only on a small skin handle is seen on the hand, it is recommended to remove it as early as in neonatal age, even under local anesthesia. If the extra finger is almost complete or has grown on top of another finger, it is recommended to remove the extra finger of the hand at the age of 1-2 years after having an X-ray.

Testicular varicose vein (varicocele)

Description of the disease: Abnormal dilation of the vessels of the testicle and scrotum.

Symptoms: The presence of dilated, tortuous vessels above the affected testicle and on the scrotum. The testicle may be painful or atrophic. If the process is on the right side, there may be an underlying abdominal tumor!

Treatment: Different classifications are known. Observation is essential as if there are no complaints or testicular shrinkage, the wide varicose veins only fill upon increased intraabdominal pressure in a standing position, surgery is not necessary. Ultrasound and surgical follow-up are warranted every 6 to 12 months. If the blood vessels are spontaneously dilated in a standing position, with chronic pain and testicular shrinkage, surgery is indicated: during abdominal keyhole surgery (laparoscopy), the affected varicose vein is occluded. Thus, the venous circulation of the testicles takes place in a different way (through collaterals). Without treatment, testicular shrinkage and sperm production disorder may develop in the long term. After laparoscopic surgery, there is a 20% chance of developing a water hernia, and it absorbs spontaneously in most cases. If not, surgical treatment of the water hernia is also necessary.

Gallstones

Description of the disease: Stones form in the gallbladder. These can cause gallbladder inflammation, inflammation of the pancreas, and cancerous degeneration in the long run.

Symptoms: Right upper abdominal pain is the most common symptom in children. In case of infants, it may be behind “intangible” abdominal complaints. These are most often discovered as a random ultrasound finding.

Treatment: Asymptomatic, silent gallstones should be followed. Gastroenterological follow-up is essential! If the stone is symptomatic or has previously caused gallbladder inflammation, surgery is indicated (laparoscopic cholecystectomy, i.e. gallbladder removal during abdominal keyhole surgery). Surgery is also indicated for small gallbladder stones.