Scientific Letter
Midline cervical cleft: A rare anomaly
Hendidura cervical media: una enfermedad poco frecuente
Yurema González Ruizc,
, Pedro Luis Burgués Pradesa, Guillermo Rodríguez Márquezb, Rafael Leonardo Fernández Atuána, Alexander Siles Hinojosaa
Corresponding author
a Servicio de Cirugía Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, Spain
b Servicio de Cirugía Plástica, Hospital Univeristario Miguel Servet, Zaragoza, Spain
c Pedro Luis Burgués Prades, Guillermo Rodríguez Márquez, Rafael Leonardo Fernández Atuány Alexander Siles Hinojosa Servicio de Cirugía Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
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Hinojosa" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Yurema" "apellidos" => "González Ruiz" "email" => array:1 [ 0 => "yuremagr@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Pedro Luis" "apellidos" => "Burgués Prades" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Guillermo" "apellidos" => "Rodríguez Márquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Rafael Leonardo" "apellidos" => "Fernández Atuán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Alexander" "apellidos" => "Siles Hinojosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Plástica, Hospital Univeristario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pedro Luis Burgués Prades, Guillermo Rodríguez Márquez, Rafael Leonardo Fernández Atuány Alexander Siles Hinojosa Servicio de Cirugía Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hendidura cervical media: una enfermedad poco frecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3150 "Ancho" => 2083 "Tamanyo" => 264074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1: (A) MCC with superior nipple-like skin projection. (B) Z-plasty in case 1, 1 month post surgery, allowing cervical retraction and mobility. Patient 2: (A) MCC with very small superior nipple-like skin tag. (B) Z-plasties in case 2 after finishing surgical treatment. Patient 3: MCC hindering cervical extension. Patient 4: Small MCC manifesting with neck hyperextension.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Midline cervical cleft (MCC) is a defect in the development of the anterior region of the neck that accounts for 2% of congenital malformations of the neck,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> and some authors consider it within the spectrum of branchial arch developmental abnormalities.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Its aetiology is unknown, and it is characterised by 4 main features: an atrophic mucosal surface, a subcutaneous fibrous cord, a caudal sinus tract and a nipple-like skin projection. Given the risk of complications, the first line of treatment is surgical excision with performance of Z-plasties to prevent anterior neck contracture, respiratory distress, micrognathia and infection and for aesthetic reasons.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of 4 patients operated for correction of MCC in our hospital, whose clinical and demographic characteristics can be found in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Of the 4 patients, 3 were male, and their age at the time of surgical intervention ranged from 8 to 18 months. None had a relevant personal history or associated malformations. All patients had the lesion at birth and patient 4 had undergone a biopsy of the nipple-like skin tag in a different facility at age 3 months, leading to a histological diagnosis of mixed hamartoma of the skin. In all patients, the lesions exhibited the 3 main features of MCC: an atrophic surface, a blind sinus at the inferior end, and a retractile fibrous cord (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Patient 1 also had a nipple-like protuberance at the superior end, as can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Patient 2 had a minimal nipple-like skin tag. In all patients, the lesion was more apparent on neck hyperextension, and in patient 3 it hindered the full extension of the neck. All patients underwent surgical excision of the lesion through a longitudinal incision in the neck, with removal of the tissue to the level of the infrahyoid muscles and closure by Z-plasty. In every case, histological examination revealed a fistulous tract lined by a keratinising squamous epithelium, sheathed in a double layer of epithelial cells (outer cuboidal layer and inner columnar layer) without atypical or malignant cells.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The embryopathogenesis of MCC has not been established, although several theories have been proposed, the most widely accepted being the impaired fusion of the first or second branchial arches during the third and fourth weeks of embryonic development.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a> Other theories include the presence of amniotic adhesions and vascular anomalies leading to tissue ischaemia, necrosis and scarring of the developing branchial arch, or increased pressure on the developing cervical area from the adjacent pericardial roof during the fifth week of gestation.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> However, these theories do not account for the presence of glandular tissue, cartilage, and skeletal muscle in the subcutaneous tissue.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Midline cervical cleft usually manifests early after birth with 4 main features: an atrophic mucosal surface, a caudal sinus that may have a mucoid discharge, a fibrous cord of variable length that may extend from the lower border of the mandible to the upper border of the manubrium, which in severe cases may limit extension, as occurred in patient 3 in our study, and less frequently a nipple-like skin tag. The lesion is superficial, located in the midline, and the superficial muscles of the neck remain intact.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2,4</span></a> It is believed that the traction of the cord on the mandibular bone during development may produce abnormalities such as exostosis, micrognathia and cleft mandible, so surgical intervention should be performed at an early stage. Midline cervical cleft may be associated with other malformations in the region, such as thyroglossal duct cyst, ectopic bronchogenic cyst, cleft tongue, lower lip and mandible or cleft sternum,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and can also be associated with cardiac anomalies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The diagnosis of MCC is clinical and can be made based on the findings of physical examination, although a cervical ultrasound scan may be performed to rule out potential comorbidities. In addition, the differential diagnosis must include other diseases that are more common, such as thyroglossal or subcutaneous bronchogenic cysts of the neck.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a> Bronchogenic cysts of the neck may be associated with MCC, as histologically they have an inner lining of ciliated pseudostratified columnar epithelium overlying a smooth muscle wall containing seromucous glands and more rarely cartilage plates, similarly to MCC.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment consists in the complete removal of the lesion with closure by means of Z-plasties, as this method avoids the formation of a vertical scar and is thus less likely to result in wound contracture, while allowing lengthening of the skin in the anterior neck.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, MCC is an infrequent disease, yet one that clinicians should be aware of on account of its potential complications. Surgical intervention should be performed early to prevent these complications, such as anterior neck contracture, respiratory distress, micrognathia and infection.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: González Ruiz Y, Burgués Prades PL, Rodríguez Márquez G, Fernández Atuán RL, Siles Hinojosa A. Hendidura cervical media: una enfermedad poco frecuente. An Pediatr (Barc). 2019;90:310–312.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3150 "Ancho" => 2083 "Tamanyo" => 264074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1: (A) MCC with superior nipple-like skin projection. (B) Z-plasty in case 1, 1 month post surgery, allowing cervical retraction and mobility. Patient 2: (A) MCC with very small superior nipple-like skin tag. (B) Z-plasties in case 2 after finishing surgical treatment. Patient 3: MCC hindering cervical extension. Patient 4: Small MCC manifesting with neck hyperextension.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patient 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patient 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patient 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patient 4 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Female \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personal history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Associated malformation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrophic surface tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fibrous band \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Caudal sinus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nipple-like protuberance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical retraction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-surgical followup<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2022446.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Age at time of surgery in months.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Duration in years.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical and demographic characteristics of the patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of congenital midline cervical cleft" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.W. McInnes" 1 => "A.D. Benson" 2 => "C.G. Verchere" 3 => "J.P. Ludemann" 4 => "J.S. Arneja" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Craniofac Surg" "fecha" => "2012" "volumen" => "1" "paginaInicial" => "36" "paginaFinal" => "38" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital midline cervical cleft: case report and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.R. Ercöcen" 1 => "S. Yilmaz" 2 => "H. Aker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Oral Maxillofac Surg" "fecha" => "2002" "volumen" => "60" "paginaInicial" => "580" "paginaFinal" => "585" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Midline cervical cleft: review of an uncommon entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. Puscas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Int J Pediatr" "fecha" => "2015" "volumen" => "2015" "paginaInicial" => "209418" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hendidura superficial media de cuello" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Sánchez López Tello" 1 => "M. Alaminos Mingorance" 2 => "J.C. Valladares Mendías" 3 => "E. Redondo Luque" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Cir Pediatr" "fecha" => "2002" "volumen" => "15" "paginaInicial" => "110" "paginaFinal" => "113" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of congenital midline cervical cleft with congenital heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Hirokawa" 1 => "H. Uotani" 2 => "H. Okami" 3 => "K. Tsukada" 4 => "T. Futatani" 5 => "I. Hashimoto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Pediatr Surg" "fecha" => "2003" "volumen" => "38" "paginaInicial" => "1099" "paginaFinal" => "1101" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009000000005/v1_201905020905/S2341287919300547/v1_201905020905/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009000000005/v1_201905020905/S2341287919300547/v1_201905020905/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287919300547?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
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| 2023 September | 54 | 20 | 74 |
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| 2020 November | 59 | 19 | 78 |
| 2020 October | 66 | 24 | 90 |
| 2020 September | 70 | 13 | 83 |
| 2020 August | 77 | 6 | 83 |
| 2020 July | 54 | 20 | 74 |
| 2020 June | 50 | 9 | 59 |
| 2020 May | 49 | 18 | 67 |
| 2020 April | 43 | 13 | 56 |
| 2020 March | 25 | 5 | 30 |
| 2020 February | 37 | 9 | 46 |
| 2020 January | 48 | 19 | 67 |
| 2019 December | 69 | 20 | 89 |
| 2019 November | 33 | 9 | 42 |
| 2019 October | 37 | 6 | 43 |
| 2019 September | 47 | 12 | 59 |
| 2019 August | 45 | 12 | 57 |
| 2019 July | 28 | 15 | 43 |
| 2019 June | 64 | 23 | 87 |
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