Branchial fistula: CT manifestations

Giant benign neoplasm of lateral neck

Branchial cleft anomalies are the second most common congenital head and neck lesions to arise in the neck.Second branchial cleft cyst typically presents as a nontender, painless, smooth, and round neck mass located along the upper third of the anterior border of the sternocleidomastoid muscle which may acutely increase in size after an upper respiratory infection.The aim of this article was to illustrate a case of a giant second branchial cyst 8 cm in diameter that was surgically treated at the Department of Maxillo-Facial Surgery of Sant'Andrea Hospital in Rome.

Report of a complete second branchial fistula

We report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa. Cysts, fistulas, and sinuses of the second branchial cleft are the most common developmental anomalies arising from the branchial apparatus. In our case, a 43-year-old man presented with a several-year history of a discharging sinus from the right side of his neck, consistent with a branchial fistula. He underwent various investigations and finally was treated with a one-stage complete surgical excision of the fistula tract. We describe the general clinical presentation, investigations, and surgical outcome of this case.

Management of Congenital Third Branchial Arch Anomalies: A Systematic Review

OBJECTIVE: To systematically review the existing literature on third branchial arch anomalies and suggest guidelines for their management.

DATA SOURCES: We searched PubMed, Medline, and Embase using Scopus, and collected additional publications cited in bibliographies. We included all English-language articles and all foreign-language articles with an English abstract.

REVIEW METHODS: Two investigators reviewed all cases explicitly identified as third arch anomalies or meeting anatomical criteria for third arch anomalies; they assessed presentation, diagnostic methods, intervention, and outcome.

RESULTS: We found 202 cases of third arch anomalies; they presented primarily on the left side (89%), usually as neck abscess (39%) or acute suppurative thyroiditis (33%). Barium swallow, direct laryngoscopy, and magnetic resonance imaging were the most useful diagnostic tools. The recurrence rate varied among the treatment options: incision and drainage, 94 percent; endoscopic cauterization of the sinus tract opening, 18 percent; open-neck surgery and tract excision, 15 percent; and partial thyroidectomy during open-neck surgery, 14 percent. Complications after surgery appeared somewhat more frequently in children eight years of age or younger.

CONCLUSION: Third arch anomalies are more common than previously reported. They appear to be best treated by complete excision of the cyst, sinus, or fistula during a quiescent period. Repeated incision and drainage yields high rates of recurrence and should be avoided. Complications might be minimized by first initiating antibiotic treatment, delaying surgical treatment until the inflammatory process is maximally resolved, and by using endoscopic cauterization.

Branchial cleft cyst versus dermoid cyst of digastric triangle: report of two cases

Lateral neck soft tissue masses manifests with variable etiologies, clinical signs and symptoms. Although these lesions are congenital in nature, manifestations of these may not occur until adulthood. Also some of these lesions may undergo malignant transformations.We present two cases with lateral neck swellings which were excised successfully under general anaesthesia and later confirmed histopathologically as dermoid and branchial cleft cysts.Formulation of an appropriate diagnosis is necessary and requires a clinician to bear a host of skills to systematically arrive at a correct treatment plan. Use of advanced imaging techniques such as ultrasonography and magnetic resonance imaging along with proper knowledge of anatomy, pathology and application of basic surgical principles goes a long way in successful and uneventful management of such lesions, as these may overlap many important neurovascular structures or may in turn be wrapped by them.

Branchial anomalies in the pediatric population

OBJECTIVE

We sought to review the presentation, evaluation, and treatment of branchial anomalies in the pediatric population and to relate these findings to recurrences and complications.

STUDY DESIGN AND SETTING

We conducted a retrospective study at a tertiary care pediatric hospital.

PATIENTS

Ninety-seven pediatric patients who were treated for branchial anomalies over a 10-year period were reviewed. Patients were studied if they underwent surgical treatment for the branchial anomaly and had 1 year of postoperative follow-up; 67 children met criteria, and 74 anomalies were studied.

RESULTS

Patients with cysts presented at a later age than did those with branchial anomaly fistulas or sinus branchial anomalies. 32% of branchial anomalies were previously infected. Of these, 71% had more than one preoperative infection. 18% of the BA were first arch derivatives, 69% were second arch derivatives and 7% were third arch derivatives. There were 22 branchial cysts, 31 branchial sinuses and 16 branchial fistulas. The preoperative and postoperative diagnoses differed in 17 cases. None of the excised specimens that contained a cystic lining recurred; all five recurrences had multiple preoperative infections.

CONCLUSIONS

Recurrence rates are increased when there are multiple preoperative infections and when there is no epithelial lining identified in the specimen.

[Diagnostic imaging of piriform sinus fistulas]

OBJECTIVES

To establish the usefulness of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and barium contrast swallow studies in the diagnosis of piriform sinus fistulas (PSF).

MATERIAL AND METHODS

We reviewed the clinical histories and imaging studies of four pediatric patients diagnosed with PSF. Cervical ultrasound was the first imaging study performed in all cases. Three patients subsequently underwent intravenous contrast-enhanced CT examination and one underwent MRI. Barium contrast swallow studies were performed in all patients at a later time. All cases were confirmed at surgery.

RESULTS

Ultrasound enabled the lesions to be located on the left side and showed the existence of heterogeneous collections in and around the thyroid glands in all four patients. Posterior CT and MRI studies determined the exact size of the abscessed lesions. Barium contrast swallow studies demonstrated the existence of the PSF in all four cases.

CONCLUSIONS

The presence of a recurrent inflammatory process and acute suppurating thyroiditis located on the left side should raise suspicions of PSF. Both CT and MRI are useful in the study of PSF; however, in our experience, ultrasound examination is the technique of choice for initial evaluation and follow-up. After the acute process, barium swallow studies continue to be the main method for diagnosing the trajectory of the fistulous tract.

Congenital piriform fossa sinus tract presenting as an asymptomatic neck mass in an infant

BACKGROUND

A 5-month-old girl with an asymptomatic left-sided neck mass was demonstrated by ultrasound and upper gastrointestinal series (UGI), and confirmed at surgery, to have a congenital piriform fossa sinus tract (CPFST) that communicated with an intrathyroidal cyst.

OBJECTIVE

To demonstrate a case of CPFST presenting as an asymptomatic neck mass. Nearly all cases of CPFST present with infection or pain, making this case unique.

MATERIALS AND METHODS

Case report and review of the literature.

CONCLUSIONS

CPFST with an associated cyst should be added to the differential diagnosis of asymptomatic cystic neck masses in infants, especially if the cyst is intrathyroidal by ultrasound.

Imaging studies of pyriform sinus fistula

BACKGROUND

Pyriform sinus fistula (PSF) refers to a persistent embryologic third or fourth pharyngeal pouch, which typically presents as a congenital sinus tract that originates from the pyriform sinus. The sinus tract is often diagnosed by a barium study or direct endoscopic inspection. Utilization of advanced imaging studies, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), may aid in the diagnosis of this disease entity.

OBJECTIVES

To review the imaging findings of PSF and demonstrate the value of various cross-sectional imaging (US, CT, and MRI) in the diagnosis of PSF.

MATERIALS AND METHODS

PSF in five children was verified surgically. Preoperative barium esophagography, US, CT, and MRI were performed selectively in these patients. The clinical and imaging findings are reviewed retrospectively.

RESULTS

Barium studies demonstrated the sinus tract in all five patients. US, CT, and MRI demonstrated an associated inflammatory process. By utilizing the trumpet maneuver, the presence of sinus tract was evident in two patients during US. The sinus tract is also demonstrated by CT in another patient.

CONCLUSIONS

Although barium esophagography is advantageous in demonstration of the sinus tract in PSF, US and CT are also capable of showing the sinus tract. The extent of inflammatory process related to PSF is better delineated by US, CT, and MRI.

A new role for computed tomography in the diagnosis and treatment of pyriform sinus fistula

Neck abscess located in or around the thyroid gland should raise the suspicion of acute suppurative thyroiditis, pyriform sinus fistula, a 3rd or 4th branchial cleft anomaly. Differentiating between these entities on a clinical basis is difficult. After treating the initial infection, computed tomography, barium esophagography, ultrasound, and endoscopy can be used in search of the fistulous tract that can be associated with a pyriform sinus fistula or a 3rd or 4th branchial anomaly. We present a case of a pyriform sinus fistula involving the use of oral contrast, combined with computed tomography, to delineate the tract and its surrounding structures. This method, in combination with endoscopy, aided in the removal of this branchial anomaly.

Third branchial cleft anomaly presenting as a retropharyngeal abscess

Branchial cleft anomalies are congenital developmental defects that typically present as a soft fluctuant mass or fistulous tract along the anterior border of the sternocleidomastoid muscle. However, branchial anomalies can manifest atypically, presenting diagnostic and therapeutic challenges. Error or delay in diagnosis can lead to complications, recurrences, and even life-threatening emergencies. We describe a case of an infected branchial cleft cyst that progressed to a retropharyngeal abscess in a 5-week-old female patient. The clinical, radiographic, and histologic findings of this rare presentation of branchial cleft cyst are discussed.

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.

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.

Recurrent suppurative thyroiditis due to pyriform sinus fistula: a case report

Acute suppurative thyroiditis is a rare disease, particularly in childhood. We present a case with recurrent acute suppurative thyroiditis due to a pyriform sinus fistula originating from the fourth branchial pouch. The typical symptoms of a pyriform sinus fistula are recurrent left-sided pain and swelling of the neck with signs of acute bacterial inflammation. Diagnosis should be made by high resolution ultrasound, barium meal studies and endoscopic examination. During acute exacerbations treatment with antibiotics is indicated, but permanent cure can only be attained by complete fistulectomy.