Branchial cleft anomalies: hybrid "Branchial Inclusion" theory

Malignancy and "Violated Neck" Rates in Consecutive Cohort of 79 Adult Patients With Solitary Cystic Neck Mass-Lessons Learned and Recommendations for Clinical Practice Guidelines

OBJECTIVE

The neck region is a common site for solitary cystic neck mass (SCNM) of various etiologies, including congenital, inflammatory, and neoplastic. In adults, the primary focus is excluding malignancy. The objective of this study was to retrospectively analyze the accuracy of available diagnostic technologies for the differentiation of benign and malignant SCNM in adult patients. The study aimed to develop new clinical practice guidelines for evaluating and managing SCNM.

METHODS

The primary predictive variables were the diagnostic utilities of fine-needle aspiration cytology (FNAC), ultrasound (U/S), multislice computed tomography, and magnetic resonance imaging. The study's endpoint was the overall diagnostic accuracy in differentiating between benign and malignant SCNM. The final diagnosis was based on histopathology.

RESULTS

The study included 79 adult patients: 55 (69.62%) male and 24 (30.38%) female ( P <0.05). The mean age at presentation was 42.1 years (range: 18-84 years). Solitary cystic neck mass was distributed in the anterior neck region in 30 (37.97%) patients and the posterolateral neck regions in 49 (62.03%) patients ( P <0.05). The posterolateral neck regions had a significantly higher rate of malignant SCNM than the anterior neck region [19/49 (38.78%) versus 1/30 (3.33%)] ( P <0.05). There was no statistically significant difference between the U/S+FNAC and U/S+FNAC+multislice computed tomography and/or magnetic resonance imaging groups in differentiating benign and malignant SCNM (40/42 versus 36/37, P >0.05). "Violated neck" was recorded in 2 cases.

CONCLUSION

A systematic investigation protocol should be applied to evaluate adult patients with SCNM.

Treatment of Work Type II Congenital First Branchial Cleft Anomalies: A Summary of 35 Cases

Objective: This study aims to summarize the data and treatment of 35 children with Work type II congenital first branchial cleft anomalies (CFBCAs) to provide significant insights into the correlation between these anomalies and the facial nerve. Methods: A total of 35 children diagnosed with Work type II CFBCAs who received treatment at the Department of Otolaryngology-Head and Neck Surgery at Shenzhen Children's Hospital from August 2017 to March 2023 were analyzed retrospectively. Pearson chi-square tests and Fisher's exact tests were used to examine the relationship between clinical characteristics and the location of the lesion, which included the superficial and deep surfaces as well as the area between the branches of the facial nerve. Results: All 35 children underwent open incision and complete resection of fistulae. During the surgery, the lesions were found to be in the superficial facial nerve in 12 (34.3%) cases, between branches in 5 (14.3%) cases, and in the deep facial nerve in 18 (51.4%) cases. In those patients, lesions in females, with a lower edge of the lesion located below the angle of the mandible and the presence of a tympanic membranous attachment, are more likely to be located deep to the facial nerve or between its branches. The difference is statistically significant (P = .007, .032, .015). Conclusion: The treatment principle of Work type II CFBCAs consists of achieving a quiescent stage of inflammation, followed by a complete resection of the lesion on the premise of preserving facial nerve function. Certain clinical features of this disease can predict the relationship between the lesion and the facial nerve. The lesions in females, with a lower edge of the lesion located below the angle of the mandible, non-cystic type of Olsen, and the presence of tympanic membranous attachment, tend to be located deep to the facial nerve or between its branches.

Congenital second branchial cleft anomalies in children: A report of 52 surgical cases, with emphasis on characteristic CT findings

Objective

The objectives of this study was to review the clinical features and surgical treatment outcomes of congenital second branchial cleft anomalies (CSBCAs) and to investigate the characteristic computed tomography (CT) findings of CSBCAs.

Methods

We conducted a retrospective study of 52 children who were referred to Shanghai Children's Hospital from October 2014 to December 2021 diagnosed as CSBCAs.

Results

There were 36 males and 16 females. Of them, 35 patients were presented as having a skin pit at birth or discharge from the skin opening on the lateral neck, and 17 patients presented with an asymptomatic or painful mass. The typical CT features of CSBCAs included isolated and homogeneously hypodense cystic lesions surrounded by a uniformly thin, smooth wall. CSBCAs were generally located at the anteromedial border of the sternocleidomastoid muscle, posterior to the submandibular gland, and lateral to the carotid sheath. All patients were treated surgically and only one case underwent ipsilateral tonsillectomy. After a median follow-up of 30 (range 4-90) months, no recurrence or complications were observed.

Conclusions

The CSBCAs show some characteristic CT findings, which can help clinicians diagnose and plan surgical strategies. High ligation of the lesions is sufficient for complete excision of CSBCAs.

Lateral neck cyst surgery without ipsilateral tonsillectomy: a retrospective analysis

PURPOSE

Several theories have been proposed regarding the origin of lateral neck cysts (LNC). Besides complete surgical resection ipsilateral tonsillectomy and dissection of a tract or its remnants is sometimes recommended. In this retrospective trial we wanted to evaluate if patients, who received LNC resection only, develop complications or recurrence to justify this surgical strategy.

METHODS

Patients who received LNC resection between 2004 and 2017 at the Ear Nose and Throat Department of a university hospital were included. Data was collected from the clinic database and through a structured telephone interview.

RESULTS

A total of 126 patients met the inclusion criteria. In this collective, the diagnosis of a lateral neck cyst was confirmed histologically. Mean age at time of operation was 38 years (± 14.6). The median follow-up time was 7 years (range 3-18). None of the participants experienced recurrent unilateral pharyngitis or tonsillitis during follow-up. Furthermore, there was no case of postoperative peritonsillar, neck phlegmon or neck abscess. No patient reported recurrence of LNC.

CONCLUSIONS

Sole complete resection of LNCs is sufficient to avoid postoperative infections and recurrences. Therefore, ipsilateral tonsillectomy and tract dissection is not necessary in routine cases of LNC surgery.

Prognostic significance of cystic nodal metastasis in HPV-positive oropharyngeal cancer

This is a brief communication stressing some critical points associated with cystic nodal metastasis (CNM) in human papillomavirus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC) and its implication on treatment protocols and outcomes.

Heterotopic squamous epithelial inclusion cyst in a cervical lymph node in a child: a case report and literature review

BACKGROUND

A squamous epithelial inclusion cyst in a lymph node is a rare heterotopic phenomenon. Heterotopic squamous inclusion cysts in cervical lymph nodes are even rarer, and to date, only 3 such cases have been reported in the literature, none of which have described the ultrasound features. Here, we report a pediatric case, focusing on the ultrasonographic manifestations of the disease and the differential diagnosis of cervical space-occupying lesions in children.

CASE DESCRIPTION

We report the case of a 6-year-old boy in good health, who presented with a non-tender mass on the right side of the neck 1 month earlier. Some 7 days before admission, the mass gradually increased in size and became tender. Laboratory tests showed an increase in C-reactive protein of 17 mg/L (normal range: 0-8 mg/L). The physical examination revealed a palpable 3.0 cm × 2.0 cm mass with tenderness and poor mobility in the right submandibular region. Doppler ultrasonography showed an oval, ill-defined mass in the right submandibular area, consisting of a peripheral homogeneous hypoechoic component with hilar-like vascularity and an internal heterogeneous very hypoechoic component with patchy hyperechoic areas. The computed tomography (CT) scan showed a heterogeneously hypodense mass with irregular annular enhancement in the right submandibular region. Lymph node tuberculosis or space-occupying lesions were suspected based on the clinical and imaging findings. The mass was completely excised by surgery. The pathological diagnosis was a secondary infection of squamous epithelial inclusion cysts in the right cervical lymph node. The peripheral homogeneous hypoechoic component was normal lymph node tissue, and the internal heterogeneous very hypoechoic component was a squamous inclusion cyst with keratin debris. The patient was followed up for a total of 3 times after surgery, and no recurrence of the tumor was found.

CONCLUSIONS

Ultrasonography can help in the early diagnosis of heterotopic squamous inclusion cysts in children's cervical lymph nodes, and can be used to differentiate other cervical lesions. We reviewed the literature and found that this heterotopic phenomenon was more likely to occur in the submandibular region of the neck in younger patients. Surgery may be an effective treatment for this disease.

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System

PURPOSE

Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs.

METHODS

Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study.

RESULTS

The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05).

CONCLUSION

The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

First branchial cleft anomaly extending to parapharyngeal space

First branchial cleft anomalies are quite rare, and the majority of them are found in and around the ear canal, mostly superficial to the facial nerve. Very rarely, the anomalous tract of the first branchial cleft can go deeper to the facial nerve, necessitating a meticulous and extensive surgery. A 21-year-old student presented with slowly increasing cystic swelling in the infra-auricular region. Findings of the magnetic resonance imaging were consistent with the first branchial cleft cyst, which also exhibited a deeper extent of the lesion into the parapharyngeal space. The entire tract was excised along with the superficial parotidectomy by an open approach. In addition to illustrating the presentation and management of this peculiar case, the present report also reviews the latest literature around their management.