Branchial cleft and pouch anomalies in childhood: a report of 50 surgical cases

Does thyroglossal duct arborization play a role in the post-surgical outcome of Sistrunk procedure in children?

PURPOSE

The purpose of the present study is to analyze thyroglossal duct cyst (TGDC) histopathological features, with focus on "arborization", in a cohort of pediatric patients who underwent surgical removal, and evaluate a possible correlation with clinical recurrences.

METHODS

A retrospective analysis of all patients who underwent surgical resection for TGDC at the division of Pediatric Surgery of the University of Pisa from 2015 to 2020 was performed; for each patient, the following data were recorded: age, sex, clinical presentation, localization, size of the lesion, diagnostic tools, histopathological features, perioperative complications, recurrence and follow-up.

RESULTS

With respect to arborization, following histopathological analysis 25/30 patients (83.3%) presented thyroglossal duct branching. After a median follow-up of 3.5 years, only 2 out of 30 patients (6.7%), one male and one female, respectively aged 4 y.o. and 6 y.o., presented recurrence within one year from first surgery.

CONCLUSION

Surgery for TGDC remains a challenge for pediatric surgeons, while arborization was present in most of our cases which underwent surgery. With respect to the role of arborization, our study did not highlight sufficient conclusive data regarding their role in recurrence: instead, it showed wide resection as satisfactory, being the arborization present in most of the cases at histopathology.

Percutaneous injection of sclerosant agents as an effective treatment for cystic malformations of the head and neck

PURPOSE

To evaluate the clinical and aesthetic outcome of percutaneous injection of sclerosant agents to treat head and neck cystic malformations (HNCM) and to assess their recurrence rate based on histology and site.

METHODS

Fifty-four subjects (mean age 46 years) with HNCM treated by percutaneous injection of sclerosant agents between January and December 2017 were included. Imaging and clinical data before and after the procedure were collected. Quality of Life Index, Pain Visual Analogue Scale, and Aesthetic Scale scores were measured to assess clinical and aesthetic outcomes. A size reduction of ≥ 70% assessed through the visual scale was considered significant.

RESULTS

Of the 54 HNCM, there were 26 (48%) lymphatic malformations (LM), 13 (24%) salivary epithelial duct cysts of the parotid gland, 12 (22%) salivary mucoceles, and 3 (5%) branchial cysts. A significant size reduction and a satisfactory clinical-aesthetic outcome were observed in all types of LM. The number of reinterventions was significantly associated with the number of lesions (p < 0.001). The lowest number of interventions was observed in macrocystic lymphatic malformations (average of 1.2 interventions). All salivary epithelial duct cysts showed a significant reduction in size, a satisfactory clinical-aesthetic outcome, and an average of 1.16 interventions per patient. Mucoceles had a worse response, with only 3/14 patients showing a satisfactory and long-lasting clinical outcome (average of 1.16 interventions). Treatment of branchial cysts showed the worst outcome with a limited clinical response (3/3).

CONCLUSION

Percutaneous injection of sclerosant agents may be considered as a first-line treatment for LM and salivary epithelial duct cysts.

Age-related outcomes after pediatric branchial cleft cyst excision via NSQIP-P

OBJECTIVE

Branchial cleft cysts present at varying ages; sometimes excision is delayed because of concern about operating in small children. Our goal was to determine if outcomes and complications differed among pediatric age groups.

STUDY DESIGN

Retrospective, cross-sectional.

SETTING

American College of Surgeons' National Surgical Quality Improvement Pediatric database.

METHODS

Patients who underwent a branchial cleft cyst excision between 2016 and 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database. Patients with CPT code 42,815: 'excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx' as their primary procedure were included. Variables of interest included patient demographics, comorbidities, pre-operative risk factors and complications.

RESULTS

2267 patients with median age of 3.9 (IQR: 7.4, range: 0.04-17.9) years were included. The most common pre-operative risk factors were 149 (7 %) patients with prematurity, 136 (6 %) with developmental delay, 135 (6 %) with congenital malformation, and 128 (6 %) with open wound or wound infection. 68 (3 %) patients experienced at least one post-operative complication, with 73 post-operative complications documented in total. Surgical site infections were the most common complications with 49 (67.1 %) superficial infections, 11 (15.1 %) deep infections, and 4 (5.5 %) organ/space infections. Surgical site infections were the most common reason for related readmission. Duration of anesthesia and operative time increased significantly as patient age increased (p < .001 for both). There was no significant correlation between age and complication incidence.

CONCLUSION

Branchial cleft cyst excision is a relatively safe operation with a low complication rate, even in young pediatric populations.

The Role of Ipsilateral Tonsillectomy in the Extirpation of Branchial Cleft Anomalies- A Retrospective Monocentric Analysis Over 13 Years

Backround

Branchial cleft anomalies (BCA) can occur as sinuses, fistulas or cysts. They arise from the first, second, third or fourth pharyngeal cleft due to non-fusion or subinvolution. Mostly, located in Robbin's neck-level II, BCA clinically present as a painless compressible swelling, cutaneous draining sinus, or fistula.

Aims

Surgical treatment is the gold standard to prevent recurrence in BCA, though the necessity of ipsilateral tonsillectomy is discussed and was being examined within this work.

Methods

In retrospect, data was collected from patients, that were admitted with the diagnosis BCA between 2006 and 2020 in an academic tertiary care center. 160 patients met inclusion criteria, the data was further evaluated, the focus was set on the occurrence of recurrence.

Results

Recurrence of BCA was observed in 2 out of 160 surgically treated patients (1,25%), one of them with simultaneous tonsillectomy, the other without.

Conclusion

A statistically significant difference in the recurrence-rate between these two groups (with/without tonsillectomy) could not be shown. The performance of an ipsilateral simultaneous tonsillectomy in the surgical workup of BCA cannot be recommended at the basis of our data.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03543-5.

The Outcome of Treatment in Second Branchial Cleft Anomalies: A Case Series

Background Branchial-cleft anomalies are second only to thyroglossal duct anomalies among congenital malformations of the neck, and second branchial-cleft anomalies are the most common. These include branchial cysts, branchial sinuses, and branchial fistulas. Clinical symptoms include neck swelling and a discharging sinus or fistula opening. In a small number of cases, they can lead to major complications like abscesses or malignant changes. Surgical resection is the treatment of choice. Various approaches to resection and sclerotherapy have been tried. In this study, we present our treatment outcome with branchial cleft anomalies at a rural tertiary medical care hospital. Objectives To document the various presentations, clinical features, and outcomes of treatment with second branchial cleft anomalies. Methods This retrospective observational study included 16 patients operated on for second branchial-cleft anomalies. A detailed medical history was elicited, and an accurate clinical examination was done. A contrast-enhanced computed tomography (CECT) scan was done in all cases. A few cases required a fistulogram. The cysts, sinuses, or fistulas were resected en bloc by a single neck crease incision. Primary closure was done in all cases. A recurrence or pharyngocutaneous fistula required axial flap reconstruction. The complications and recurrences were documented. Result There were six children and 10 adults in our study. Seven cysts, five sinuses, and four fistulas were present, of which four were iatrogenic. In seven patients, imaging could not show the entire tract. There were four fistulas from the oropharynx to a cutaneous opening in the neck. A complete resection was done for all. Two pharyngocutaneous fistulas were treated with a pectoralis major myocutaneous (PMMC) flap. Three patients had wound dehiscence postoperatively. None of the patients had neurological or vascular injuries. Conclusion Second branchial cleft anomalies can be completely excised by a single neck crease incision. Meticulous surgery results in a low recurrence or complication rate. Following complete excision, in type IV anomalies, a purse-string suture at the pharyngeal opening ensures good closure and no recurrences.

First Branchial Cleft Cyst Confined to the Pinna

First branchial cleft cysts (FBCCs) arise due to an incomplete fusion of the cleft between the first and second branchial arches. Classically, they are found inferior to the pinna or along the external auditory canal. This report presents a unique case of a nine-month-old male with a first branchial cleft cyst completely within the pinna. The patient presented with a left auricular pit and pinna mass. Ultrasound revealed a homogeneous hypoechoic mass isolated to the pinna. Surgical resection revealed the cyst to be anterior to the inferior pinna cartilage, with the tract projecting anteriorly and inferiorly. Final pathology revealed a benign cyst lined by squamous epithelium and a rim of cartilage, confirming an FBCC. To our knowledge, FBCCs isolated to the pinna have not been previously reported. Awareness of the various presentations of this rare anomaly is essential for a prompt and accurate diagnosis.

Horn-shaped Symmetric Nodules on the Earlobes: An Unusual Presentation of First Branchial Cleft Anomaly

First branchial cleft anomaly (BCA) is a rare congenital malformation of the head and neck, <10% of all BCA. it occurs between the first and second branchial arches. The diagnosis of first BCA is often delayed because of its atypical shape and rarity. A 30-year-old male presented to our clinic with bilateral earlobes nodules, he first noticed ~20 years prior. The lesions had gradually increased in size, and he stated no other specific symptoms. Bilaterally, a 1-cm-sized, sharp, horn-shaped, dark-colored, keratinized mass was palpated hardly, and no infectious signs were observed. Bilateral resection was performed, and the lesions did not form a tract in any other direction. Histopathology confirmed the lesions were first BCA composed of a cystic cavity lined by stratified squamous epithelium. Surgeons should suspect first BCA in patients with nonspecific lesions of the earlobe, and our case will help with future diagnoses.

Postauricular Incision Versus Conventional Transcervical Incision in Second Branchial Cleft Cyst Excision: A Systematic Review and Meta-Analysis

Surgical removal is the treatment of choice for second branchial cleft cysts (SBCCs), which are congenital anomalies. The conventional procedure is performed through a transcervical approach, which would lead to a visible scar in the anterior neck. Conversely, the postauricular approach could keep the scar in the hairline or retroauricular sulcus, rendering it almost invisible after the surgery. The purpose of this meta-analysis was to evaluate the differences between the postauricular and conventional transcervical approaches to SBCC excision. A systematic review was performed using PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes of SBCC surgery via postauricular and conventional transcervical approaches. The data of interest were analyzed with Comprehensive Meta-Analysis software (version 3). The data of interest were analyzed by calculating the risk difference (RD), the standardized mean difference, and the mean difference (MD) with the 95% confidence interval (CI). Three studies were eligible for the final analysis. The pooled analysis demonstrated that the cosmetic satisfaction score was significantly higher with the postauricular approach (standardized mean difference, 2.12; 95% CI, 0.68–3.56). The operative duration was significantly longer with the postauricular approach than with the conventional transcervical approach (MD, 12.81; 95% CI, 2.39–23.23). The incidences of postoperative marginal mandibular nerve palsy (RD, 0.00; 95% CI, −0.09 to 0.09), bleeding complications (RD, −0.02; 95% CI, −0.09 to 0.05), salivary complications (RD, −0.00; 95% CI, −0.07 to 0.06), cyst size (MD, 0.02; 95% CI, −0.96–0.99), and length of hospital stay (MD, −2.50; CI, −7.30 to 2.30) were comparable between the 2 groups. The postauricular approach is feasible for use in SBCC excision and yields better cosmetic outcomes, a longer operative duration, and a similar rate of complications.

A complete second branchial fistula in a four years old child

INTRODUCTION AND IMPORTANCE

Second branchial anomalies either cyst, sinus, or fistula are the top differential diagnosis of lateral neck masses or swelling in pediatrics age group. Yet, it is very rare for the branchial fistula to have two openings.

CASE PRESENTATION

Here we present a four years old child diagnosed with complete branchial fistula by CT scan with dye injection throughout the fistula tract. We successfully managed him by complete surgical resection. Also, we provide the current literature that aids in the diagnosis and treatment of complete second branchial fistula.

CONCLUSION

Complete second branchial fistula is not that common anomaly; however, we must consider it as a differential diagnosis in any lateral neck masses. Complete surgical resection, step ladder approach, which will minimise the recurrence rate is the treatment of choice.

Coexistence of thyroglossal duct cyst and second branchial cleft cyst in a young woman: A case report and literature review

Introduction

Thyroglossal cysts represent 70% of congenital neck anomalies, and second branchial cleft anomalies are the most common anomalies (90%) of the branchial apparatus. However, their coexistence, especially in adults, is very rare.

Presentation of case

A 23-year-old woman presented with a 1-year history of lateral left neck swelling and midline swelling. Imaging and histopathological examination confirmed the diagnosis of a thyroglossal duct cyst and a second branchial cleft cyst. The Sistrunk procedure was performed for surgical excision of the masses.

Discussion

Only three cases of a coexisting thyroglossal duct cyst and branchial cleft have been reported.

Conclusion

When encountering patients, even adults, with neck lesions, clinicians must keep in mind the possibility of a coexistence of a thyroglossal duct and a branchial cleft cyst.

•

Thyroglossal cysts represent 70% of congenital neck anomalies.

•

Second branchial cleft anomalies are the most common branchial apparatus anomalies.

•

Only three cases of coexisting thyroglossal duct and branchial cleft cysts have been reported.

•

We present a rare case of a young woman with the two cysts coexisting.

Branchial cleft cyst associated with xanthogranulomatous inflammation – An unusual case

Rationale:

Patient Concerns:

Diagnosis:

Treatment:

Outcomes:

Take-away Lessons:

An unexpected cyst of the ear lobule

Branchial cleft anomalies (BCA) are among the most common congenital anomalies found in the pediatric head and neck. The embryology of these congenital anomalies is well understood, which allows clinicians to anticipate their diagnosis when a pediatric patient presents with a head or neck mass. The predictable anatomy of the various types of BCA allows for improved surgical planning to prevent recurrence and ensure complete resection. This report details an unusual location of a first BCA located in the ear lobule of a 10-month old male. There has been no documented first BCA at the ear lobule in the literature.

A Systematic Literature Review to Compare Clinical Outcomes of Different Surgical Techniques for Second Branchial Cyst Removal

Objective:

During the last 2 decades, new treatment methods have been developed for the surgical removal of second branchial cysts which result in less visible scars. The aim of this systematic review is to assess which surgical technique for second branchial arch cyst removal results in the lowest complication and recurrence rates with the highest scar satisfaction.

Methods:

Two authors systematically reviewed the literature in the Cochrane, PubMed, and EMBASE databases (search date: 1975 to December 2nd, 2020) to identify studies comparing surgical outcomes of second branchial arch cyst removal. Authors appraised selected studies on directness of evidence and risk of bias. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Results:

Out of the 2442 retrieved articles, 4 articles were included in the current review including a total of 140 operated cysts. Only 2 studies included pre-operatively infected cysts. Follow up ranged from 3 to 24 months. Complication rates ranged from 0 to 27.3% (conventional: [0–10.4%]; endoscopic/retro-auricular: [0–27.3%]). None of the patients presented with postoperative recurrence. Significantly higher scar satisfaction was found in adult patients who underwent endoscopic or retro-auricular hairline incision cyst removal.

Conclusion:

No recurrence of disease occurred during (at least) 3 months of follow up using either conventional surgery or endoscopic/retro-auricular techniques. Although more (temporary) complications occur using endoscopic and retro-auricular techniques, patients report a significantly higher scar satisfaction 3 to 6 months after surgery in comparison to the conventional technique. Future studies are needed to support these findings.

Clinical and ultrasound characteristics of pediatric lateral neck masses

Lateral neck masses (LNM) often present a diagnostic challenge in the practice of pediatric plastic surgeon. The aim of this study is to investigate the clinical and ultrasound (US) characteristics of pediatric LNM in order to make mutual comparison between their entities and enable the most accurate preoperative diagnosis. A cross-sectional study was conducted among 250 pediatric patients treated by surgical excision or sclerotherapy in our institution in the period from July 2009 to June 2019. Lymphatic malformation was the most frequent congenital LNM (60.9%), while reactive or granulomatous lymphadenitis was the most frequent acquired LNM (47%). Congenital anomalies were significantly more often localized in the upper half of the sternocleidomastoid (SCM) muscle region, and had more often soft consistency than acquired ones. Congenital LNM had a 32.37 (3.44–304.63) times higher likelihood of incorrect (p = 0.002) and 5.86 (1.35–25.48) times higher likelihood of undetermined (p = 0.018) than correct US findings, respectively. Acquired LNM were significantly more often localized in the region behind the SCM muscle and more often had solid US appearance in comparison to the congenital ones. Association of the clinical and US findings is very important in determining the most accurate preoperative diagnosis without exposing the children to unnecessary utilizing ionizing radiation or anesthesia. Although they are mostly benign, extreme caution is necessary due to malignancies which were found in 16.4% of all our patients.

Clinical Manifestations, Diagnosis, and Management of First Branchial Cleft Fistula/Sinus: A Case Series and Literature Review

PURPOSE

First branchial cleft fistula/sinus is a rare congenital developmental deformity that can sometimes be acquired from incision and drainage of a branchial cleft cyst. The aim of the present study was to explore the clinical manifestations, diagnosis, and surgical management of first branchial cleft fistula/sinus in both a large patient series and a review of the pertinent literature.

MATERIALS AND METHODS

The data from 31 cases diagnosed from February 2004 to April 2019 as first branchial cleft fistula/sinus were retrospectively reviewed. The patient demographic data and outcomes were explored. In addition, we performed a literature review of studies reported from 1923 to 2018 for first branchial cleft fistula/sinus and summarized those results.

RESULTS

The present study included 31 patients (15 males, 16 females) with a median age of 4 years. All the patients reviewed had presented with a unilateral first branchial cleft fistula/sinus. The parotid region was the most frequent site of presentation (41.9%) in these cases. The fistula/sinus had occurred on the left side in 13 patients (41.9%) and on the right side in 18 patients (58.1%). Of the 31 patients, 24 (77.4%) had acquired the disease from infection of an existing brachial cleft cyst or incomplete previous excision. Of the 31 cases, 28 (90%) had an intimate relationship between the tract and the facial nerve. Despite this close association, no patient developed postoperative facial nerve palsy. Of the 31 operations, 30 (97%) successfully accomplished complete resection with no recurrence postoperatively. Only 1 patient with a history of multiple recurrences experienced a subsequent recurrence, which was successfully treated with a second surgery.

CONCLUSIONS

First branchial cleft fistula/sinus is a frequently misdiagnosed and, therefore, undertreated entity, which leads to recurrence. It is closely associated with the facial nerve and extra auditory canal. The correct diagnosis and meticulous removal can be effectively achieved with minimal risk to the facial nerve.

A Branchial Cyst in a Diamond Python (Morelia spilota)

A 9-year-old female diamond python (Morelia spilota) was presented with a submandibular swelling. The cytological, macroscopic and histological features of this lesion indicated a diagnosis of branchial (pharyngeal) cyst. Branchial cysts are benign lesions caused by anomalous development of the branchial apparatus and are described rarely in veterinary medicine. We suggest that possible persistence of branchial remnants should be included in the consideration of differential diagnoses for neck masses in adult snakes.

The utilization of selective neck dissection in the treatment of recurrent branchial cleft anomalies

To investigate the characteristics of recurrent branchial cleft anomalies (BCAs) and to evaluate the surgical technique and outcomes of patients undergoing reoperation.From January 2005 to August 2018, the clinical data of 216 patients with recurrent second, third, and fourth BCAs were retrospectively analyzed. According to the embryological and anatomical features of the cleft palate and recurrence site, selective neck dissection techniques were used for surgical treatment.Among all 216 patients, 203 healed by primary healing. Twelve patients with local infections and 1 patient with a pharyngeal fistula healed after dressing changes. Eleven patients experienced transient hoarseness and recovered after a few months. Three patients developed permanent hoarseness, and 5 patients developed coughing after eating and drinking. Three patients underwent internal jugular vein ligation. Only 4 recurrences occurred during a follow-up period of more than 1 year. The total cure rate was 98.15%.Selective neck dissection is an effective and safe surgical treatment for recurrent second, third, and fourth branchial cleft anomalies.

The Microbiology Characteristics of Infected Branchial Cleft Anomalies

Objectives

To investigate the microbiology profile of infected branchial cleft anomalies compared to deep neck infection and explore the influence of age on culture findings.

Study Design

A retrospective case control study.

Setting

A single tertiary medical center.

Subjects and Methods

Patients treated for branchial cleft anomalies between 2006 and 2016 were included. Demographic data, disease and treatment parameters, and microbiology profile, including bacteria classification, antibiotics resistance patterns, and number of pathogens, were analyzed.

Results

Of 278 cases treated for branchial cleft anomalies, we have analyzed 69 cases with infection and pathogen identification. The proportion of monobacterial infections was higher (70.6% vs 44.3%; P = .003; odds ratio [OR], 3.02) and the proportion of Streptococcus species infection was lower (48.9% vs 77.2%; P = .001; OR, 0.282) among the infected branchial cleft cases compared to deep neck infections. Anaerobic bacteria infection did not differ between groups (17.8% and 16.5%, respectively). There was a nonsignificant tendency toward more resistant bacterial strains among the infected branchial clefts (15.6% vs 6.3%; P = .118; OR, 2.726). There was no difference between the bacterial profile of patients younger or older than 16 years.

Conclusions

The microbiology profile of infected branchial cleft anomalies is not age related and is different from that of deep neck infections. We demonstrate a relatively high frequency of monobacterial infections, relatively lower streptococcal infection rates, and a substantial contribution by resistant species and anaerobes. Empiric antibiotic treatment should cover Streptococcus species, including penicillin-resistant species, as well as clindamycin-resistant anaerobes.

A cross-sectional evaluation of outcomes of pediatric branchial cleft cyst excision

OBJECTIVE

To examine complications following pediatric branchial cleft cyst excision by surgical specialty, demographics, and comorbid conditions.

METHODS

A retrospective review of the National Surgical Quality Improvement Program database was performed. Pediatric cases from January 1, 2015 through May 1, 2017 with a current procedural terminology code of 42810 (excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) or 42815 (excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx) were included. Statistical analysis was performed to assess associations between complications and surgical specialty, demographics, and comorbidities.

RESULTS

Of the 895 cases that met inclusion criteria, the median age was two years and there was an approximately equal number of males (46.8%) and females (53.2%). Forty-five patients (5.0%) experienced at least one 30-day complication, the most predominant of which was superficial surgical site infection. There was no statistically significant difference between complications and surgical specialty, complications and patient demographics, or complications and depth of excision. There was a statistically significant difference (p = 0.05) in the percentage of patients with a past medical history of developmental delay between those with at least one complication (11.1%) compared to those without any complications (4.2%).

CONCLUSION AND RELEVANCE

Branchial cleft excision is a generally safe procedure across surgical specialties and patient demographics. There is an association between a history of developmental delay and 30-day postoperative complications.

Efficacy and Safety of Ethanol Ablation for Branchial Cleft Cysts

BACKGROUND AND PURPOSE

Branchial cleft cyst is a common congenital lesion of the neck. This study evaluated the efficacy and safety of ethanol ablation as an alternative treatment to surgery for branchial cleft cyst.

MATERIALS AND METHODS

Between September 2006 and October 2016, ethanol ablation was performed in 22 patients who refused an operation for a second branchial cleft cyst. After the exclusion of 2 patients who were lost to follow-up, the data of 20 patients were retrospectively evaluated. All index masses were confirmed as benign before treatment. Sonography-guided aspiration of the cystic fluid was followed by injection of absolute ethanol (99%) into the lesion. The injected volume of ethanol was 50%-80% of the volume of fluid aspirated. Therapeutic outcome, including the volume reduction ratio, therapeutic success rate (volume reduction ratio of >50% and/or no palpable mass), and complications, was evaluated.

RESULTS

The mean index volume of the cysts was 26.4 ± 15.7 mL (range, 3.8-49.9 mL). After ablation, the mean volume of the cysts decreased to 1.2 ± 1.1 mL (range, 0.0-3.5 mL). The mean volume reduction ratio at last follow-up was 93.9% ± 7.9% (range, 75.5%-100.0%; P < .001). Therapeutic success was achieved in all nodules (20/20, 100%), and the symptomatic (P < .001) and cosmetic (P < .001) scores had improved significantly by the last follow-up. In 1 patient, intracystic hemorrhage developed during the aspiration; however, no major complications occurred in any patient.

CONCLUSIONS

Ethanol ablation is an effective and safe treatment for patients with branchial cleft cysts who refuse, or are ineligible for, an operation.