Branchial anomalies in children: A report of 105 surgical cases

Congenital Sternoclavicular Sinus-Case Series of a Rare Lower Neck Deformity

OBJECTIVES

We encountered patients with a congenital cutaneous sinus tract in the sternoclavicular joint region, which we designate as "congenital sternoclavicular sinus (CSCS)." The aim of this investigation is to enhance recognition of this subtle yet noteworthy entity and develop standardized protocols for its management.

PATIENTS AND METHODS

Between 2013 and 2023, 172 patients, including 78 males and 94 females, were referred to our institution for the management of CSCS. Clinical charts were retrospectively reviewed.

RESULTS

The majority of patients (60.5%) were young children below 3 years of age, with only six adult patients and a median age of 27.5 months. The left side was implicated in 157 cases (91.3%). In 146 cases (84.9%), a faint skin streak was noted above the orifice. Yet, no pharyngeal sinus tracts were detected, either through barium swallow studies or direct laryngoscopy. All skin lesions featured a diminutive orifice near the sternoclavicular joint, with the tract extending deeply into the subcutaneous tissue and terminating blindly, short of entering the joint, after a distance of 10 mm (ranging from 5 to 21 mm). Histopathological analysis revealed that the epithelial lining predominantly consisted of stratified squamous epithelium (87.8%), with ciliated columnar epithelium accounting for the remaining 12.2%.

CONCLUSIONS

CSCS, though infrequent, presents with distinctive pathological and clinical features. The condition predominantly affects the left sternoclavicular joint region, with the notable "skin streak sign" aiding in diagnosis. We considered CSCS as one disease entity of branchial arch anomalies. Complete surgical excision offers a definitive cure.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Sonographic Findings of Cervical Chondrocutaneous Branchial Remnants-A Comparison With Dermal Lesions/Cysts and a Literature Review: A Pilot Study

OBJECTIVES

Cervical chondrocutaneous branchial remnants (CCBRs) and dermal lesions, such as epidermoid cysts or brachial anomalies, including lateral cervical cysts/sinuses or dermal sinuses of anterior chest lesions, are usually located at the lower neck at the anterior or posterior border of the sternocleidomastoid muscle (SCM). We aimed to demonstrate the usefulness of ultrasonography in the differential diagnosis and evaluation of CCBRs.

METHODS

We evaluated 22 lesions of 20 pediatric patients, classified into CCBR and dermal lesion groups. We used Fisher's exact test to evaluate differences between these groups in terms of lesion shape (low-echoic mass- or tubular-like), whether the lesion was adjacent to/in contact with the SCM or not, and the presence or absence of a concave SCM caused by the lesion.

RESULTS

Of the 22 lesions, 8 were CCBRs, and 14 were dermal lesions. We found a significant difference in the presence/absence of adjacency to or contact with the SCM (presence/absence of adjacency to or contact with the SCM in CCBRs vs that in dermal lesions: 6/2 vs 1/13, P = .002) and presence/absence of lesion-induced concavity of the SCM (presence/absence of lesion-induced concavity of the SCM in CCBRs vs that in dermal lesions: 3/5 vs 0/14, P = .036). The lesion shape (low-echoic mass-like/tubular-like lesions) did not significantly differ between the two study groups (low-echoic mass-like/tubular-like lesions in CCBRs vs that in dermal lesions: 5/3 vs 11/6, P = .624).

CONCLUSIONS

CCBRs have a strong association with the SCM. These sonographic findings may be useful in the differential diagnosis of dermal cervical lesions.

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.

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.

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.

The congenital sternoclavicular sinus: a single-institution retrospective study of 88 patients

BACKGROUND

Sinus near the sternoclavicular joint was considered as a rare congenital neck abnormality. Though it was reported as a dermoid sinus in some literatures, the embryological origin of the sinus was unclear. This study aimed at reviewing the clinical and histological characteristics and analyzing the possible embryological origin of this malformation in children.

METHODS

The medical records of all patients with congenital sternoclavicular sinus who underwent surgical resection between March 2018 through June 2020 were reviewed retrospectively. The clinical presentations, complications, histological examination, and treatment were analyzed.

RESULTS

Of the 88 patients with congenital sternoclavicular sinus included, the mean age of surgery was 2.73 ± 1.71 years old. The sinuses occurred on the left side in 73 (83.0%) cases. Sixty-three patients experienced sinus infection and 44 patients underwent incision and drainage before excision. All patients received surgical resection with one patient who recurred after surgery. Histopathological examination showed that the sinuses were lined by squamous epithelium in most patients. However, ciliated epithelium was observed in one patient and salivary glands were detected in two patients.

CONCLUSIONS

The congenital sternoclavicular sinus should be excised promptly to prevent recurrent infection. According to the ciliated epithelium and salivary gland were found in the wall of sinus, it should be viewed as the skin side remnant of the fourth branchial cleft rather than a dermoid cyst/sinus.

Imaging Findings in Neonates With Congenital Pyriform Sinus Fistula: A Retrospective Study of 45 Cases

Background: Congenital pyriform sinus fistula (CPSF) is a rare branchial cleft deformity. The characteristics and management of CPSF in neonates are different from those in children or adults, and a comprehensive understanding of the imaging features of neonatal CPSF can facilitate its preoperative diagnosis. Thus, the aim of this study was to summarize the ultrasonography (US) and CT imaging findings of CPSF in neonates. Methods: Forty-five full-term neonates with CPSF, confirmed by pathology after surgical resection from January 2012 to October 2020, were included in this retrospective study. All patients underwent preoperative cervical US and contrast-enhanced CT examinations, and the imaging findings were analyzed. Results: Forty-six cervical cystic masses were found in 45 neonates, including one case with bilateral lesions, three cases with lesions on the right side, and 41 cases on the left side. Both US and CT detected neck abnormality among all cases, while the diagnostic accuracy of US (15/46, 32.6%) was lower than that of CT (42/46, 91.3%). Moreover, CT showed significantly higher detection rates of intralesional air bubbles, involvement of the ipsilateral thyroid, deviation of the airway, and expansion into the mediastinal and retropharyngeal space compared with the US. As the age increased, it was more likely to present some features including the absence of air-containing, thick cyst wall, and poorly defined border (ρ <0.05). Conclusion: CPSF in the neonates showed distinctive imaging findings on contrast-enhanced CT scan, which provides important supplementary information for the diagnosis of CPSF after the initial US examination.

Pathophysiology of aspiration in a unilateral SLN lesion model using quantitative analysis of VFSS

OBJECTIVE

The purpose of this study was to elucidate the pathophysiology of aspiration in previously studied female infant piglets after a unilateral superior laryngeal nerve (uSLN) lesion.

METHODS

Videofluoroscopic swallow studies (VFSS) were acquired from 15 female piglets ages 2-3 weeks (9 with uSLN lesion and 6 controls). VFSS were analyzed at 30 frames/second sampling rate. Quantitative measures were conducted and compared between groups using published methodologies for VFSS assessment in adult and infant humans. Measures included the: 1) number of lingual-palatal contacts (LPC) (i.e. pre-swallow), 2) total pharyngeal transit time (TPT), 3) offset of swallow (offP), as well as onset of: 4) pharyngeal stage (onP), 5) pharyngoesophageal segment opening (oPES), 6) maximum PES opening (maxPES), 7) airway closure onset (oAC), and 8) maximum airway closure (maxAC). Measures 5-7 were determined relative to onP. Bolus residue was rated by severity (0 (none) to 3 (severe)). A gamma regression was used to compare continuous measures between lesioned and control groups.

RESULTS

The number of LPC (p = .006), TPT (p = .023) and timing of maxAC (p = .041) were significantly greater in the uSLN lesion than the control group.

CONCLUSIONS

Outcomes of this study replicated prior published findings and elucidated that piglets with right uSLN lesions exhibited delayed maxAC. Noteworthy was the use of clinically relevant quantitative videofluoroscopic measures in piglets for comparison to future studies in human pediatric populations.

Second branchial cleft fistula/sinus tract endoscopy: a novel intraoperative technique assisting complete surgical resection

PURPOSE

Second branchial cleft (BC) sinus/fistula anomalies usually present in children. Their definitive management requires complete tract surgical excision, which necessities accurate extension assessment. Our aim is to propose and describe a novel intraoperative endoscopic technique that can help in evaluating the exact BC anomaly tract extension and overcome disadvantages of currently used methods including imaging and intraoperative methylene blue tract injection.

METHODS

The innovative intraoperative endoscopic technique involves performing BC sinus/fistula tract intraluminal endoscopy utilizing miniature 1.3 or 1.6 mm all-in-one semi-rigid endoscopes as well as other accessory equipment currently available and used for sialendoscopy for delineation of exact tract extension followed by a complete standard surgical excision tailored to and assisted by the endoscopic procedure.

RESULTS

This novel endoscopic technique was used successfully in five children (age range 8-16 years) presenting with unilateral or bilateral congenital second BC discharging fistula/sinus tracts in the neck. Intraoperative endoscopic assessment took 10-15 min and confirmed the exact tract extension and nature in all patients without complications. Five fistulas and two sinuses were identified and completely surgically resected. No recurrence has been observed after a median follow-up of 29 (range 13-45) months.

CONCLUSION

Intraoperative second BC fistula/sinus tract endoscopy could help in accurately assessing anomaly extension, thereby assisting in complete surgical excision. This innovative novel endoscopic technique could avoid disadvantages of currently used methods, especially regarding radiation exposure required for imaging children in whom this anomaly usually presents.

Surgical Management of an Intrathoracic Branchial Cyst in a Yellow-crested Cockatoo (Cacatua sulphurea)

A 40-year-old, female lesser crested cockatoo (Cacatua sulphurea) was presented with a complaint of hyporexia and sudden onset of sneezing and wheezing. Physical examination revealed mild stertorous inhalation, and the apex of the heart was palpable caudoventral to the distal tip of the sternum. Projection radiographic images showed a soft tissue mass displacing the heart and the thoracic portion of the trachea. A subsequent computed tomography series revealed a single, large, and predominantly encapsulated soft-tissue mass. The mass was contained within the cranial thoracic region and occupied most of the anatomic location of the thoracic portion of the clavicular air sac, extending around a portion of the trachea. A surgical exploratory procedure was performed, with a thoracic inlet thoracotomy, and the mass was found to be cystic and deeply attached to surrounding tissues at its caudal-most aspect. Complete excision was not possible, and the mass was drained and an incomplete resection was accomplished with approximately one-half of the cystic structure removed and submitted for histopathology. The mass was found to be benign, epithelial-lined, dense, fibrous connective tissue that would be consistent with a branchial cyst.

Open Surgical Excision Versus Endoscopic Radiofrequency Ablation for Piriform Fossa Fistula

OBJECTIVES

The purpose of this study is to explore the curative effect of open surgical excision and endoscopic radiofrequency ablation (RA) in the treatment of piriform fossa fistula (PSF).

METHODS

Retrospective study of 80 cases of PSF in the Department of Otolaryngology-Head and Neck Surgery, Shanghai Children's Hospital, from June 2009 to June 2017.

RESULTS

In this series, there were 43 males and 37 females, and the mean age was 5.2 years (17 days to 12 years). Surgical excision was performed for 62 patients. Radiofrequency ablation was performed for 18 patients. Six cases of postoperative temporary hoarseness occurred, and the hoarseness rates were not significantly different between the excision and RA groups (6.4% vs 11.1%, respectively, P = .88). Two cases of temporary neck abscess occurred in the RA group. After the mean follow-up period of 3.1 years (1-8 years), no recurrence was found between the excision and RA groups.

CONCLUSIONS

The curative effect of excision and RA for PSF is not significantly different; each of the 2 methods has its advantages and disadvantages. However, RA for PSF has the merit of being minimally invasive, easy to operate, and safe; this procedure seems to be more suitable in the clinic.

Resection of recurrent third branchial cleft fistulas assisted by flexible pharyngotomy

BACKGROUND

Treatment of fistulas arising from the third branchial cleft includes endoscopic cauterization or open cervical fistulectomy. Both approaches are associated with recurrence rates of 14%-18%, and possibly greater rates when the fistula has been treated operatively beforehand. Treatment of fistulas arising from the third branchial cleft is associated with an inordinate recurrence rate. Recurrence may be multifactorial and related to incomplete resection of all of the anatomical elements of the fistula.

AIM

To present a new approach that involves complete resection of the recurrent fistula by a combined therapeutic approach.

METHODS

Here, 12 adult patients diagnosed with recurrent third branchial cleft fistulas underwent a combined therapy assisted by flexible fiber-optic pharyngoscopy to identify and resect the entry site of the fistula into the pyriform sinus. The fistulous opening into the pyriform sinus was identified by flexible fiber-optic pharyngoscopy. The application of intubation with a guidewire by pharyngoscopy, in addition to the removal of the partial excision of the thyroid cartilage, allowed complete resection of the opening and all parts of the fistula tract.

RESULTS

All of the internal openings of the fistulas in the pharynx were found and easily identified by flexible fiber-optic pharyngoscopy. All of the 12 patients underwent complete resection of the recurrent fistula by the combined therapeutic approach. There were no postoperative complications such as parapharyngeal abscess or wound infection, injury or dysfunction of the recurrent laryngeal or superior laryngeal nerves. The pharyngeal edema had degraded, and the pharyngeal wound healed postoperatively within 1 wk. Laryngeal endoscopy and voice analysis were performed on the 14th d post-operatively. Vocal cord movements did not change. The characters of voice for jitter, shimmer, and normalized noise energy were all within normal limits. In addition, no recurrences were observed during the 13-60 mo follow-up period.

CONCLUSION

It can be concluded that the proposed combined therapy is associated with excellent results, minimal morbidity, and no recurrence.

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.

Ectopic salivary gland fistula in the sternoclavicular joint region

Although rare, ectopic salivary gland fistula should be considered in the differential diagnosis when treating a fistulous lesion on the neck because its natural history and the level of difficulty of surgery are different from those of the branchial fistula.