Branchial cleft and pouch anomalies

Treatment of piriform fossa sinuses with monopolar diathermy

Introduction:

Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition.

Materials and methods:

A retrospective, case report review was performed.

Results:

Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months.

Discussion:

Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.

A third branchial pouch cyst presenting as stridor in a child

We present a rare case of a third branchial pouch cyst in an 18-month-old child, presenting with stridor and a lateral cervical cystic mass. Differences in the anatomical course of third and fourth branchial cysts, and histological differences between branchial pouch and branchial cleft cysts are discussed.

Congenital Cervical Cysts, Sinuses and Fistulae

Congenital cervical anomalies are important to consider in the differential of head and neck masses in children and adults. These lesions can present as palpable cystic masses, infected masses, draining sinuses, or fistulae. Thyroglossal duct cysts are most common, followed by branchial cleft anomalies, dermoid cysts, and more rarely median cervical clefts. Other topics discussed include median ectopic thyroid, cervical teratomas, and branchiootorenal syndrome. Appropriate diagnosis and management of these lesions requires a complete understanding of their embryology and anatomy. Correct diagnosis, resolution of infectious issues before definitive therapy, and complete surgical excision are essential to prevent recurrence.

A Third Branchial Pouch Cyst Presenting as a Lateral Neck Mass in an Adult

Anomalies of the branchial apparatus occur with some frequency in the adult and pediatric populations. Branchial anomalies are most often derivatives of the first or second pouch. Branchial anomalies involving the third pouch may present as cysts, sinuses, fistulas, and ectopic glands. They are relatively rare, and they respond well to surgical removal. We report the case of a 53-year-old woman who was referred to us for evaluation of a persistent left upper neck mass. The patient had no history of a cervical mass as a child or young adult. The mass was excised uneventfully, and the final pathology revealed a normocellular parathyroid gland and thymic tissue.

Branchial cleft and arch anomalies in children

Branchial anomalies are important lesions to consider in the differential diagnosis of head and neck masses in children. These anomalies are composed of a heterogeneous group of congenital malformations that arise from incomplete obliteration of pharyngeal clefts and pouches during embryogenesis. Although present at birth, many abnormalities do not become evident until later in infancy or childhood. It is common for branchial anomalies to become infected, causing significant morbidity. Surgical removal may be difficult, and inadequate resection of the lesion is likely to cause recurrence. Understanding the embryology and anatomy of these lesions is essential to the provision of adequate therapy.

Lumps and bumps in neonates and infants

There are many developmental abnormalities that may appear in the neonate and in infants when critical steps in embryogenesis fail. These steps are often not fatal but can lead to significant morbidity for those patients affected. A logical approach is needed in addressing both the diagnostic and therapeutic issues that arise when caring for these patients, as various lesions will warrant an observational approach, and others may require imaging studies or definitive surgical intervention. Additionally, there are other "lumps and bumps" that are seen in the neonatal and infantile age groups that include malignancies and cutaneous neoplasms with associated systemic sequelae.

A new fistulectomy method for the second pharyngeal arch remnants

PURPOSE

We present a new fistulectomy method for the second pharyngeal arch remnants.

MATERIALS AND METHODS

Between 1991 and 2003, 4 patients have been treated with a new fistulectomy method.

SURGICAL PROCEDURE

Under general anesthesia with nasotracheal intubation, the neck and mouth are prepared as one operative field. A nylon thread is inserted into the cervical opening. On the oral site of the nylon thread, a small gauze ball is tied and gently pulled from the neck site. At both opening sites of the fistula, a very small incision around the nylon thread is performed. Using the nylon thread as a guide, a fistulectomy is carried out.

RESULTS

In all 4 patients, no complications have occurred during and after the fistulectomy. No recurrences were seen during 15 months to 9 years.

CONCLUSIONS

This is a simple and useful procedure for the treatment of second pharyngeal arch remnants. It produces an excellent cosmetic result compared with the standard method because only one small incision is necessary.

Second Branchial Anomalies in Children

AIM

The aim of this study was to evaluate the data of our patients who had been treated for second branchial anomalies in the last 10 years. Here we report our clinical experience in second branchial anomalies with a review of the literature.

PATIENTS AND METHODS

We evaluated retrospectively the data of 14 patients, who had been operated on between 1994 and 2004 for second branchial anomalies, in relation to age, sex, complaint at application, diagnostic test, surgical procedures and histopathologic findings.

RESULTS

The mean age of the patients (8 female, 6 male) was 5.3 years (range = 1.5-16). The anomalies were usually located on the left side of the neck (n = 6). There were only 3 cases with bilateral anomalies. The majority of the lesions were sinuses (93%). The most frequent clinical feature was the presence of persistent discharge from an external (cutaneous) orifice. All lesions were excised by performing a second step ladder incision. Eight of the lesions were removed under the guidance of 3/0 polypropylene suture. No postoperative complication or recurrence was observed during the follow-up period.

CONCLUSIONS

Second branchial arches anomalies are the most common branchial anomalies. Sinuses are more frequently encountered in children. Definitive treatment for these lesions is surgical excision. A polypropylene suture can be inserted into the tract as a guide to prevent incomplete excision.

Second branchial cleft sinus presenting after adenotonsillectomy

Branchial cleft sinuses are one of the more common congenital defects arising in the head and neck region. Second branchial cleft anomalies are the commonest of the true branchial cleft defects and the diagnosis is usually straightforward. We report the case of an atypical presentation of branchial cleft sinus that manifested after adenotonsillectomy. To our knowledge this is the first reported case of a second branchial cleft sinus presenting only after adenotonsillectomy. The sinus was excised with no recurrence of symptoms at 12 months of follow-up.

Complete fistula of the second branchial cleft: case report of catheter-aided total excision

The authors report an extremely rare case of complete fistula of the second branchial cleft, with an external opening in the skin and an internal opening in the oropharyngeal mucosa. A 13-year-old girl presented with the complaint of intermittent drainage from the right side of her neck, a problem that had existed since birth. Fistulography revealed a complete fistula of the second branchial cleft. Before surgical excision, a 4-F catheter and a 0.018-in guide-wire were inserted into the external opening of the fistula and passed through to the tonsillar region under fluoroscopic guidance. The infrahyoid segment and parapharyngeal segment of the fistula were then excised through first- and second-step neck incisions, respectively. In this case, tonsillectomy was not necessary. Pathological examination of the wall of the fistula revealed lymphoid tissue containing lymphoid follicles. This report describes a technique in which complete excision of a fistula of the second branchial arch is facilitated by placing a catheter in the tract.

Management of anomalies of the third and fourth branchial pouches

Third and fourth branchial pouch anomalies are rare and usually present as lateral neck masses, abscesses or with acute suppurative thyroiditis. An opening in the piriform sinus can be identified in most cases. We present four cases of fourth branchial pouch sinuses, one of a third branchial cyst and discuss our management. Cannulation of the sinus tract at laryngoscopy, followed by complete surgical excision, via a modified oblique thyrotomy above the cricothyroid joint after detaching the inferior constrictor was used to treat the fourth branchial pouch anomalies. This surgical approach adequately exposes the piriform sinus apex and also affords protection to the recurrent laryngeal nerve. The third pouch cyst and tract were excised at the level of the thyrohyoid membrane. There were no complications or recurrences.

A rare case of combined type I and II first branchial sinus

The authors report a rare case of first branchial sinus with combined Work's type I and type II characteristics. Instead of a sinus opening in the neck, this sinus opened above the angle of the jaw in the face. The facial nerve was significantly more superficial to the tympanomastoid suture line than normal. Early diagnosis, ensuring complete resection, and avoidance of facial nerve injury are challenging issues discussed here.

First branchial cleft sinus presenting with cholesteatoma and external auditory canal atresia

First branchial cleft abnormalities are rare. They may involve the external auditory canal and middle ear. We describe a 6-year-old girl with congenital external auditory canal atresia, microtia, and cholesteatoma of mastoid and middle ear in addition to the first branchial cleft abnormalities. Clinical features of the patient are briefly described and the embryological relationship between first branchial cleft anomaly and external auditory canal atresia is discussed. The surgical management of these lesions may be performed, both the complete excision of the sinus and reconstructive otologic surgery.

Updating concepts of first branchial cleft defects: a literature review

OBJECTIVE

The Sinuses and fistulae of first branchial cleft origin have been widely reported in the literature and their variable relationship to the facial nerve has been described. Most published series however are too small to allow a detailed analysis of the relative frequency of various relationships of these lesions to the facial nerve and therefore enabling the determination of risks to the nerve at surgery. The aim of this study was to perform a comprehensive review of literature in an attempt to identify those patients with a deep tract (lying deep to the main trunk of the facial nerve and/or its branches, and/or between the branches) and to recognize the incidence of the complications of surgical management.

METHODS

Available English, French and German literature between 1923 and 2000 was reviewed and variables including patient's age, sex, side and type of anomaly, opening of the lesion and the relationship of the tract are analyzed in relation to the position of the facial nerve. The complications due to their surgical excision are also reported.

RESULTS

Of the total number of cases with fistulae and sinuses identified (n=158) fistulous tracts were more likely to lie deep to the facial nerve compared with sinus tracts (P=0.01). Lesions with openings in the external auditory meatus are associated with a tract superficial to the facial nerve (P=0.05). Patients presenting at a younger age were more likely to have a deep tract with consequent increased risk of facial nerve damage.

CONCLUSION

Identification of the facial nerve trunk at an early stage of dissection is critical. Extra care and caution should be exercised in younger patients (<6 months), those with fistulous tracts and in patients with a tract opening elsewhere other than the external auditory canal.

Complete branchial fistula. Case report and review of the literature

Branchial anomalies, a result of aberrant embryonic development, are rarely seen in clinical practice. Lesions of the second branchial pouch commonly present as a neck lump or discharging sinus that may be complicated by infection. Clinical examination often reveals the lesion to be related to the junction of the upper two thirds and the lower one third of the sternocleidomastoid muscle. Branchial fistulas often present as a discharging sinus in the neck with the fistula tract extending upward within the deep neck tissue for a variable distance. A complete branchial fistula is one that has a defined internal opening in the tonsillar area and an external opening at the skin overlying the sternocleidomastoid muscle at the junction of the upper two thirds and the lower one third of the muscle. The incidence of such lesions is extremely rare. Surgical excision is the treatment of choice for branchial anomalies. We present the case of a patient who presented with a complete branchial fistula and discuss the clinical presentation and surgical management of such lesions, with a review of the relevant literature.

Duplication of the external auditory canal: a report of three cases

OBJECTIVE

Malformations of the first branchial cleft are uncommon and only sporadically reported in the literature. They may present as inflammatory openings on the neck, bland cysts or fistula associated with the external auditory canal. In this retrospective study, clinical features and anatomical relationships are described in three pediatric cases. Therapeutical guidelines for surgical management of first branchial cleft anomalies are discussed.

PATIENTS

Between 1997 and 1999 three patients aged 9 months, 2 and 7 years with first branchial cleft anomalies were included in this study. All patients were treated surgically, wide exposure and superficial parotidectomy was necessary for complete removal in two of three cases.

RESULTS

Exploring patients histories revealed previous infections with repeated incision and drainage procedures as well as inadequate operative resections. Clinically, purulent drainage from the ear, swelling in the parotid area and abscess formation with persistent drainage after incision in the neck or parotid area were noted.

CONCLUSIONS

From our case series two of three patients underwent inadequate incision and drainage procedures to combat infection followed by scar tissue formation. Because of the variable relation to the facial nerve this led to difficulties in identifying and protecting the nerve during definite surgery. Management of first branchial cleft anomalies must include the facilities to achieve ear surgery and superficial parotidectomy including facial nerve exposure.

Management of first branchial cleft anomalies: report of two cases

Embryological anomalies of the first branchial apparatus result in rare forms of developmental abnormality of the head and neck. Their presentation may be similar to other conditions and they may easily be overlooked by the unwary when considering the differential diagnosis of a parotid swelling or a neck sinus. Consequently, they may be mismanaged on one or more occasions. We encountered two patients in whom such problems arose and conclude that appropriate investigation and management by a team skill ed in surgery of this region is necessary if a satisfactory outcome is to be achieved.

Head and neck anomalies related to the branchial apparatus

An understanding of the branchial apparatus and its anomalies may lead to greater precision in the clinical diagnosis and management of these congenital head and neck lesions. Although branchial anomalies have been well described, controversial issues, such as the branchial origin of lateral cervical cysts and the differentiation between third and fourth branchial pouch sinuses, remain unresolved.

Congenital cysts and fistulas of the neck

This retrospective study describes a series of 191 children treated for congenital cysts and fistulas of the neck between 1984 and 1999 in the pediatric ORL Department of La Timone Children's Hospital. Preauricular fistulas and cystic hygromas were not included. The anomalies in this series were classified as either malformations of the midline or malformations of laterocervical region. Malformations of the midline included the thyroglossal duct cysts (n=102) and dermoid cysts (n=21). The most common malformations of the laterocervical region were cysts and fistulas of the second cleft (n=37) followed by those of the first cleft (n=20),those of the fourth pouch (n=7), and thymic cysts (n=4). Diagnosis of malformations of the midline is usually straightforward. However, diagnosis of malformation of the laterocervical region can be problematic. Misdiagnosis often leads to inadequate treatment with recurrence and functional as well as cosmetic sequelae.

Pyriform sinus fistula: management with chemocauterization of the internal opening

A branchial remnant originating in the pyriform sinus causes a recurrent fistula or abscess in the neck. In spite of excision, recurrence may result from inadequate removal of the fistula tract. We attempted chemocauterization of the internal opening of the fistula tract with trichloroacetic acid (TCA) on direct endoscopy. This is a 6-year review of 18 patients with pyriform sinus fistula. Medical history, barium esophagography, computed tomography scans, operative findings, and treatment results were analyzed. By direct endoscopy, all patients were found to have a fistula opening in the pyriform sinus, exclusively on the left side. In only 9 patients, the fistula tract was identified by barium esophagography before operation. Computed tomography revealed a suspicious fistula tract originating from the pyriform sinus in 8 of 10 patients. Sixteen patients were initially managed by TCA chemocauterization. There were no serious intraoperative or postoperative complications. Four patients had recurrent masses, which were managed by simple excision in 2 patients and repeated TCA cauterization in the other 2 patients with unobliterated internal openings. We recommend barium swallow study and direct endoscopy for all patients presenting with a recurrent lateral neck abscess, especially on the left side. Our results suggest that initial chemocauterization of the internal opening can be a reasonable alternative procedure for the management of pyriform sinus fistula.

Fourth branchial cyst presenting with neonatal respiratory distress

Fourth branchial cysts are quite rare. A neonate with a left lateral neck mass and respiratory distress was found to have a fourth branchial cyst, which was diagnosed with computed tomography and endoscopy. The characteristic computed tomography findings included an air-containing neck cyst, which was located at the anteromedial site of the common carotid artery with mediastinal extension. Endoscopic examination revealed an internal opening at the apex of the pyriform sinus, communicating with the cyst. Total excision of the cyst was performed, and the specimen, which showed ciliated columnar epithelium with a subepithelial lymphoid infiltrate, thyroid follicles, and thymic tissue, histologically confirmed the diagnosis.

Incidental sampling of branchial remnants: a potential source of error in fine-needle aspiration of neck lesions-a case report

Remnants of the branchial apparatus can produce lesions in the head and neck region in later life, often amenable to fine-needle aspiration (FNA) diagnosis. Yet such remnants or rudimentary lesions can remain clinically undetected and can later interfere with the cytologic interpretation of other deep lesions of the neck, as the present case demonstrates. In this case the lesion, which by a subsequent resection turned out to be a neurilemmoma, had been adequately sampled by the FNA, yet the cytologic diagnosis was sidetracked by the presence in the specimen of immature squamous epithelial tissue fragments and other elements (multinucleated histiocytes, calcifications), on the basis of which the diagnosis of an epithelial lesion, likely malignant, was made. The neck surgery and a preceding endoscopic examination of the mouth, pharynx, and larynx did not identify such a lesion, but a detailed microscopic examination of the fibroadipose tissue between the tumor and the peripharyngeal region revealed the presence of epithelial microfragments with morphology partly corresponding to that of the FNA cytology, highly indicative of a branchiogenic lesion in the peripharyngeal region. The basic embryology of the branchial apparatus resulting in such defects is presented, as well as tentative guidelines for recognizing material deriving from accidental sampling of such lesions during FNA investigations of deep-seated masses of the neck. Diagn. Cytopathol. 2000;22:157-160.

Aberrant second branchial cleft fistula

Second branchial cleft cysts and sinuses rarely present diagnostic problems to the pediatric otolaryngologist as their course is usually predictable based on consistent embryologic development. However, we evaluated two fistula tracts that did not fit the classic description of second branchial tract fistulas. Upon radiographic and intraoperative evaluation, their eventual course ending in the tonsillar fossa was identified. Realizing the potential for aberrancy and using preoperative radiographic evaluation will assist the surgeon in the excision of these developmental anomalies with little risk to underlying neurovascular structures.

Anomalias branquiais: revisão de 23 casos

A anomalia branquial é a doença congênita mais comum vista pelo cirurgião de cabeça e pescoço. Vinte e três pacientes portadores de anomalias branquiais tratados no período de 1994 a 1997 foram revisados. O diagnóstico clínico foi documentado por ultra-sonografia e comprovado pelo exame histopatológico. Encontramos seis anomalias de primeiro arco (26%); 16 do segundo arco (69,5%); e uma do terceiro (4,5%). Não houve anomalia do quarto arco. Após um seguimento que variou de três a 43 meses, não houve caso de recidiva. A prevalência de anomalias do segundo arco é compatível com a literatura, porém, foi alta a incidência do primeiro arco. O emprego da técnica cirúrgica adequada, com a ressecção de todo o trajeto fistuloso, mostrou-se eficaz.

Fourth branchial pouch anomalies: a study of six cases and review of the literature

A retrospective study in the ENT departments of the Timone Children's Hospital in Marseille and the Armand Trousseau Hospital in Paris and a review of the literature was performed in order to update knowledge about fourth branchial pouch anomalies. Over the 12-year period studied, a total of six children were treated: three boys and three girls. The lesions were located on the left side in all cases and infection was the most common manifestation. Clinical presentation ranged from suppurative thyroiditis in most cases to stridor in a few newborns. The most useful diagnostic examinations are CT-scan of the neck and endoscopy of the pyriform sinus. The authors emphasize the need for complete surgical resection including the cyst and fistulous tract down to the pyriform sinus.

[Mode of presentation of fistula of the first branchial cleft]

BACKGROUND

The rarity and diverse presentations of first branchial cleft anomalies lead to misdiagnosis and inadequate treatment.

POPULATION AND METHODS

We report 21 cases of such anomalies in children aged 7 months to 8 years whose diagnosis was presumed on clinical presentation and confirmed at surgery.

RESULTS

The symptoms were intractable otorrhea, periauricular, cervical and parotid suppuration, which were present in two, 12, five and three cases, respectively. Two children had an abnormal eardrum and three an epidermic cyst in the external ear canal.

CONCLUSION

The diagnosis of a first branchial cleft anomaly must be considered in any patient with a history of recurrent periauricular swelling, a sinus located high in the neck, or a mass in the external auditory canal.

Periauricular cysts and sinuses

Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.

Fourth branchial sinus causing recurrent cervical abscess

BACKGROUND

Three patients who presented with recurrent cervical abscesses were found to have a branchial sinus arising in the piriform fossa. Each patient had previously had cervical abscess drainage procedures.

METHODS

A retrospective review of patients with recurrent cervical abscess and associated fourth branchial sinus was carried out.

RESULTS

In each case, imaging and endoscopy identified a sinus tract from the left piriform fossa. Neck exploration with hemithyroidectomy and excision of the sinus tract was performed without further recurrence of abscess.

CONCLUSIONS

We believe these cases to represent a fourth branchial sinus. The relevant embryology and anatomy of the branchial apparatus is discussed and the pathways for the sinus and fistulous tracts of branchial sinus origin are reviewed. Branchial sinuses are uncommon, but should be considered as the underlying aetiology in patients who present with recurrent cervical abscesses.

First branchial cleft anomaly

A first branchial cleft anomaly is an unusual clinical condition and the clinical picture is similar to that seen in other much more common diseases. This combination may result in a diagnostic delay and insufficient and dangerous primary surgery, resulting in facial nerve damage. This paper reviews the embryological background of first branchial cleft anomalies, the varying clinical presentation and the surgical treatment, illustrated by three case histories. A revision of the most common classification system is proposed.

A combined approach excision of branchial fistula

Second branchial cleft and pouch anomalies are by far the commonest of the branchial anomalies. In most cases, however, there is a unilateral cleft sinus. A complete fistula with external and internal openings is rare. We present a case with a complete branchial fistula in which the tract was followed from the neck to the tonsillar fossa using a combined approach.

Branchial anomalies: a review of 52 cases

Fifty-two patients with branchial anomalies (BA) treated at the Children's National Medical Center between 1983 and 1993 were reviewed to determine the incidence of different types of anomalies and to analyze the authors' method of diagnosis and management. First BA was seen in 25%, second in 40%, third in 8%, and fourth in 2%. In 25%, the origin of the anomaly was undetermined. Our incidence of first BA was significantly higher than the incidence reported in other series. Of the anomalies, sinuses were more common than cysts or fistulae. Sinuses tend to present at an earlier age than cysts, which take time to enlarge and present clinically. Repeated incision and drainage and incomplete excisions were frequently seen with first, third, and fourth anomalies due to misdiagnosis. Recent trend has been to utilize radiographic studies more frequently, and they have been found to be helpful in guiding surgical therapy, particularly with the more complicated cases.

Unusual presentation of a first branchial cleft

An atypical case of a first branchial cleft presenting with a cutaneous fistula and an epidermoid cyst of the external auditory canal is reported. The relevant embryology of the branchial apparatus is summarized, and variations of first branchial anomalies are discussed. The relationship with a congenital cholesteatoma is discussed.

A unique congenital glossocervical fistula

Lateral cervical fistulae which communicate with the oropharynx are considered to result from incomplete obliteration of the second branchial cleft and pouch. Classically these fistulae have a well-defined pathway through the neck. We present a case, and discuss the aetiology, of a fistula extending from the lateral neck via a previously undescribed course through the neck structures and opening into the posterior aspect of the tongue at the level of the vallate papillae.

A variation of first branchial cleft anomalies

First branchial cleft anomalies are considered to be duplications of the external auditory meatus (EAM) and pinna with a sinus that runs parallel to the EAM (Type 1) or with a sinus that runs from an opening in the neck and ends blindly near the cartilaginous EAM (Type 2). In this paper we discuss a young patient that presented with an infected sinus that did not resemble either of the two known types of first branchial cleft anomalies.