Congenital cervical cysts, sinuses, and fistulae in pediatric surgery. Surg Clin North Am. 2012;92:583-597, viii. [PMID: 22595710 DOI: 10.1016/j.suc.2012.03.015]

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.

Management of first branchial anomalies in children: 20 years of experience

PURPOSE

Branchial cleft anomalies (BCAs) are common pediatric head and neck lesions; however, only 1-4% involve the first branchial cleft. The rare occurrence of first BCAs, their presentation at a young age, and the possible facial nerve involvement make diagnosis and treatment challenging.

METHODS

A retrospective chart review was conducted for children diagnosed with their first BCA between 2000 and 2020. Data on demographics, presenting symptoms, physical findings, imaging features, previous surgery, and treatment outcomes were collected and analyzed.

RESULTS

The cohort included 17 patients with a median age of 5 years at presentation. Seven (41%) had undergone previous surgical intervention before definitive surgery. Eight were classified as Work Type II anomalies, and nine as Work Type I. Sixteen patients (94%) underwent definitive surgical excision at a median age of 6.9. A parotid approach was used in 10 (62%), with dissection of the mass from the facial nerve, and a retro-auricular or end-aural approach was used in 6 (38%). Complete excision was achieved in 14/16 patients (88%). Three patients had transient facial nerve paresis postoperatively. Recurrence was noted in 3/16 patients (18%). Enhancement in imaging was positively correlated with post-operative complications (R = 0.463, P = 0.018).

CONCLUSIONS

First, BCA poses a diagnostic and surgical challenge; thus, definitive surgical treatment is often delayed. The surgical approach should be tailored to the type of anomaly (Work type I or II) and possible facial nerve involvement. Risk factors for post-operative complications are a history of recurrent infections and previous surgical interventions. The presence of contrast enhancement in preoperative imaging should alert surgeons to perioperative challenges and the risk of post-operative complications.

LEVEL OF EVIDENCE: 4

Ultimobranchial body cyst in an adult horse: clinical, histopathologic, and immunohistochemical features

A 9-y-old Mangalarga Marchador gelding was referred to a veterinary hospital because of a swelling on the upper right side of the neck. Ultrasound examination revealed a multilocular structure adjacent to the thyroid gland with low echogenic content suggestive of fluid. The mass was removed surgically. Histologically, the cystic cavities in the surgical sample were filled with abundant eosinophilic secreta and lined by cuboidal, segmentally ciliated, columnar epithelium with interspersed goblet cells. Segmental crowding of the multilayered lining of the cyst was noted. Immunohistochemistry suggested the presence of both C cells and follicular cells, given the positivity of the immunomarkers calcitonin and TTF-1, respectively. The histogenesis of ultimobranchial cysts is uncertain. Based on clinical, histopathologic, and immunohistochemical identification, the cystic structure in this case is compatible with an ultimobranchial body cyst.

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 Neck Masses

There are many possible causes of congenital neck masses, with the most common ones being thyroglossal duct cysts, branchial cleft anomalies, and vascular malformations. Most congenital neck masses are asymptomatic in the neonatal period, but depending on the location and the size, they can cause airway obstruction and serious complications at birth. Proper diagnosis is important for optimal treatment planning, and if the airway is compromised, multidisciplinary teamwork is critical for proper airway management. This review summarizes the clinical features, etiology, diagnosis, management, and prognosis of different types of congenital neck masses.

Cervical Chondrocutaneous Branchial Remnant: A Case Report and Review of the Literature

ABSTRACT

Cervical chondrocutaneous branchial remnant is a rare congenital developmental anomaly typically located on the lateral neck. Histologically, it has the appearance of an accessory tragus demonstrating a central cartilaginous core with surrounding fibrosis located in the subcutaneous tissue. The condition has been associated with a variety of congenital anomalies, particularly involving the auditory, cardiovascular, and visual systems. Given that research-based evidence related to cervical chondrocutaneous branchial remnant in dermatology literature is sparse, we present this case to raise more awareness about this entity among dermatopathologists and review the different histopathologic presentations and possible associated anomalies.

Congenital Midline Cervical Cleft and Thyroglossal Duct Fibrous Cord-Like, is There a Mixed Presentation?

INTRODUCTION

Congenital midline cervical cleft is a rare condition and is frequently misdiagnosed as thyroglossal duct cyst. Otherwise, the combination of congenital midline cervical cleft and thyroglossal duct fibrosis in the same patient is as rare as important to be registered with the intention to inform and offer specific managements details for the literature.

CASE PRESENTATION

Eight-year-old boy with simultaneous congenital midline cervical cleft and a thyroglossal duct fibrosis. The anatomic, clinical, radiologic, and pathologic characteristics of the congenital midline cervical cleft are described as well as surgical technique for removal and repair with Z-plasty.

CONCLUSION

Congenital midline cervical cleft is a rare condition and when diagnosed must be surgically treated as early as possible. Its differential diagnosis is a clinical challenge.

Transoral Robotic Excision of Paediatric Lingual Thyroglossal Duct Cyst

Lingual thyroglossal duct cyst (TGDC) is a rare variant of TGDC that emerges within the tongue base. It presents a unique surgical challenge. There are different approaches to managing this condition. Transoral robotic surgery (TORS) has been successfully used for lesions of the tongue base in adults. This report presents a 7 year old boy with a cystic lesion in the base of tongue, which was diagnosed to be a lingual TGDC. The cyst was excised transorally using Da Vinci Robotic system. The surgery was performed in a short operating time with no complications or recurrence on follow up. TORS is an effective and reliable method of excision of lingual TGDC in the paediatric population. Lingual TGDC can be managed by simple excision of the cyst without excision of hyoid bone. Further studies are needed to confirm the safety and recurrence rates of this technique in paediatric population.

Complete Second Branchial Cleft Fistulas: A Clinicosurgical Experience

A complete second branchial fistula is very rare and has an internal opening at the tonsillar fossa and an external opening at the lower third of the sternocleidomastoid (SCM). Patients commonly present with persistent or intermittent mucoid or mucopurulent discharge from an external opening. The diagnosis is most often clinical and radiological investigations are rarely needed. Treatment of choice is complete surgical excision. The aim of this article is to aware young ENT surgeons of the various clinical and intraoperative surgical findings that can be encountered while dealing with these cases. This observational study was done for a period of 10 years. A total of 20 cases of fistula were included which intraoperatively had a complete track from tonsillar fossa to neck. Excision of the tract was carried out via combined transcervical and transoral approach under general anaesthesia using two incisions in stepladder pattern. Each patient was seen after one year of surgery to assess for any recurrence. Different findings of patients including age/sex at surgery, initial presentation, family history, laterality of the fistula tract, Intraoperative surgical findings, complications, and recurrences. were noted. Of the 20 patients, 13 (65%) were females and 7 (35%) were Females. Most common complaint was fistulous opening with intermittent discharge(15patients; 75%).Branchial cleft fistulae more commonly affected the right neck (14 patients, 78%) among unilateral cases and 2 patients (10%) had bilateral fistulae. No patient had associated congenital anomaly/syndrome, family history or and visible opening in tonsillar area. Glossopharyngeal nerve was identified in 12 cases and track was seen passing lateral to it except in one case. The internal opening of track was seen over posterior tonsillar pillar in 15 cases (75%) while in 5 patient the track was seen entering tonsillar tissue or bed. Tonsillectomy was done in 5 cases while not done in 15 cases where track was seen entering posterior pillar. All patients were seen at one year follow up. No recurrence was seen at one year of follow up. Complete second branchial cleft fistulae are rare. They are usually right sided and unilateral. The track passes between carotid bifurcation and invariably passes lateral to both glossopharyngeal and hypoglossal nerves. Track usually ends at the posterior tonsillar pillar. Tonsillectomy is not routinely indicated. Recurrences are not typically seen.

Case report: Fourth branchial cleft cyst: a case of acute suppurative thyroiditis

This case report presents a 4 year-old-female patient with a neck mass who was diagnosed with an infected fourth branchial cleft cyst with left thyroid lobe involvement through fistulation. The case emphasizes the importance of considering uncommon etiologies, such as congenital anomalies, as a differential diagnosis when evaluating pediatric neck masses. The patient was prescribed broad-spectrum antibiotics, which led to the regression of the mass and inflammatory signs. Close follow-up in endocrinology and otorhinolaryngology appointments was maintained, and after 7 months, hypoplasia of the left lobe was observed. Thyroid function was reevaluated, and after two years, no recurrences were noted. The case highlights the significance of a comprehensive examination and assessment of corresponding clinical features, which can significantly reduce the rate of misdiagnoses and achieve an individualized diagnosis.

Thyroid Disorders Spectrum in Pediatric Endocrine Clinic; Seven-Year Experience of a Teaching Hospital in Saudi Arabia

Thyroid disorders constitute one of the major endocrine disorders in pediatric service. It includes a range of congenital versus acquired anatomic and/or functional thyroid diseases in growing children that has a spectrum of severity from severe intellectual disability effect to subclinical mild pathologies. This study was designed to analyze the demographic characteristics, clinical pattern, and severity of thyroid disorders in the pediatric endocrine clinic patients at the teaching hospital of the university over a 7-year duration. A total number of 148 patients with thyroid disorders were seen in pediatric Endocrine clinic during the time between January 2015 and December 2021. Female patients constitute 64% of them. Acquired Hypothyroidism was the commonest disorder; 34% of the cases followed by the congenital hypothyroidism (CH), then Hashimoto's thyroiditis, and 5.8% for others. While a very small percentage was acquired hyperthyroidism. The majority of referrals were from dermatology and other service for the screening of thyroid disease as association with other autoimmune diseases with percentage of 28.3%. Next was neck swelling manifestation in 22.6%. Thyroid disorders in children, both congenital and acquired, constitute an important medical issue for pediatricians to be aware of its variable presentations, and its potential serious health consequences on the affected children if not diagnosed and treated earlier. Acquired hypothyroidism constitutes more percentage of the thyroid disorders followed in the pediatric endocrinology outpatient clinics. Congenital hypothyroidism is the second most common thyroid disorder in the outpatient unit, having the most potential complications. These results support the international studies with the female predominance in most of thyroid disorders.

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.

Quality and Readability of Online Patient Education Materials Related to Branchial Cleft Cysts

Introduction

Branchial cleft cysts are the second most common congenital neck mass and can cause significant anxiety for patients and families despite their benign nature. Education through online patient education materials (PEMs) is critical for informing patients and reducing stress. We aimed to determine the content, quality, and readability of online PEMs related to branchial cleft cysts.

Methods

The search engine Google was used to collect the first 100 website results for the query “branchial cleft cyst.” PEMs were included and assessed for content, quality via the DISCERN tool, and readability via Flesch Reading Ease Score (FRES), Flesch-Kincaid Reading Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG).

Results

Twenty-six websites containing PEMs related to branchial cleft cysts were assessed. Most websites were from universities or medical centers and did not contain any media. The mean DISCERN score was 49.3 (SD: 11.1, Median: 52.5), the mean FRES score was 51.9 (SD: 12.1, Median: 54.0), the mean FKGL score was 10.35 (SD: 2.52, Median: 9.95), the mean GFOG score was 13.32 (SD: 2.52, Median: 13.00), and the mean SMOG score was 10.25 (SD: 1.83, Median: 9.95). DISCERN was not significantly correlated with FRES, FKGL, GFOG, or SMOG.

Conclusion

Online PEMs related to branchial cleft cysts are consistently written above the National Institutes of Health (NIH) recommended sixth-grade reading level and are often of unsatisfactory overall quality. Writers of online PEMs for branchial cleft cysts should consider the readability and quality of their materials to improve patient education and reduce anxiety.

Optimal age of surgery for children with thyroglossal duct cysts: A single-institution retrospective study of 340 patients

OBJECTIVE

The recommended age of surgery for thyroglossal duct cysts (TGDCs) in children is inconclusive. This study aimed to explore the optimal age of surgery by analyzing the natural history of the disease and the association between the age of surgery and postoperative complications.

METHODS

All TGDC patients who underwent a modified Sistrunk procedure at our hospital between March 2010 and May 2022 were reviewed retrospectively. The evaluation focused on the age of preoperative symptomatic cystic infection, pathological inflammation, postoperative wound infection, and recurrence.

RESULTS

Of the 340 patients included in the study, the median age of surgery was 47.5 months (IQR, 24.1-61.6). Preoperative symptomatic cystic infection and pathological inflammation frequencies were 27.1% (n = 92) and 48.5% (n = 165), respectively. The cumulative hazard of symptomatic cystic infection and pathological inflammation increased steadily with age. The ages of 50% cumulative incidence of symptomatic cystic infection and pathological inflammation were 97 months and 71 months, respectively. Postoperative wound infection was higher in patients of younger age (OR = 0.96, 95% CI, 0.93-0.98, P < 0.001) and with symptomatic cystic infection (OR = 8.16, 95% CI, 2.54-36.86, P = 0.002). There was no significant association between the age of surgery and recurrence.

CONCLUSION

Although wound infection was weakly associated with younger age, the symptomatic cystic infection increasing with age has a more remarkable impact on wound infection after the Sistrunk procedure. The recurrence rate did not increase in young patients receiving surgery. Therefore, the Sistrunk procedure was safe and effective at a young age, and prompt operation in children with TGDC once diagnosed was reasonable.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

Pre and postnatal diagnosis of a third branchial cleft cyst by sonography and magnetic resonance imaging with three-dimensional virtual reconstruction

Branchial cleft cysts (BCCs) are common causes of cervical tumors in children and adulthood; however, prenatal diagnosis of BCC is rare. In neonates, these cysts can suddenly increase in size, causing airway obstruction and becoming a life-threatening condition. In this case report, we describe the prenatal diagnosis of a third BCC at the 25th week of pregnancy using ultrasound, magnetic resonance imaging, and three-dimensional virtual models, as well as the perinatal outcomes of this rare condition.

[Suspected rare manifestation of a thyroglossal and lateral cervical cyst-a diagnostic and therapeutic approach]

A 34-year-old female patient presented to our department with a 1.5 cm midline cystic lesion of the neck. A second cystic mass was found in level 2 of the left lateral neck. Following complete resection, histopathological examination revealed the diagnosis of a dystopic papillary thyroid carcinoma. Total thyroidectomy and bilateral neck dissection were performed. The patient developed transient postoperative hypoparathyroidism. The specimen showed four intraparenchymal parathyroid glands. Treatment with radioactive iodine was conducted.

First branchial cleft cyst accompanied by external auditory canal atresia and middle ear malformation: A case report

BACKGROUND

We report a rare case of first branchial cleft anomaly (FBCA) accompanied by bony atresia of the external auditory canal, middle ear malformation, and location malformation of the facial nerve according to the intraoperative findings.

CASE SUMMARY

A 19-year-old male patient presented to our department with a mass behind the right earlobe and recurrent postauricular swelling and pain since childhood, he also had severe hearing loss in the right ear since birth. The patient underwent surgery including mass removal, mastoidectomy, and simultaneous meatoplasty and ossiculoplasty under microscopy. No facial palsy or recurrence was noted during postoperative follow-up.

CONCLUSION

FBCAs are rare, and to our knowledge, this is the first report of FBCA accompanied by external auditory canal bony atresia, middle ear malformation, and location malformation of the facial nerve. An effective postauricular approach under microscopy facilitated complete lesion removal and simultaneous otologic reconstruction.

Definitive surgical management for second branchial cleft fistula: a case series

Background

Second branchial cleft fistulae are rare pediatric anomalies managed with surgical excision and, in certain cases, ipsilateral tonsillectomy to prevent postoperative recurrence or wound infection. Limited information is available in the published literature regarding surgical techniques to maximize patient outcomes and minimize recurrence. Our objective was to describe outcomes for the largest series of branchial cleft fistulae excised using a uniform technique based on embryologic principles.

Methods

We conducted a retrospective analysis of pediatric patients who underwent surgery for second branchial cleft fistula using a uniform technique developed by the senior surgeon between 2006 and 2018 at a tertiary care pediatric hospital. The technique involves dissection to the level of the greater cornu of the hyoid bone as the point of transection, which is the landmark for the base of the tonsillar fossa. Data collected included age at surgery, initial presentation, laterality of fistula tract, final pathology, and follow up data. Measured outcomes included fistula recurrence, wound infection, and other complications.

Results

Of 67 patients, 28 (42%) were male and 10 (15%) had bilateral fistulae, for a total of 77 tracts excised. After a median follow up of 31 months, there were no recurrences and one wound infection that was treated successfully with oral antibiotic therapy. No patients underwent tonsillectomy.

Conclusion

Effective management of second branchial cleft fistulae can be challenging. We present the largest cohort of results using a uniform surgical technique performed at a single center that obviates the need for tonsillectomy, and thus represents a less morbid and effective approach with no evidence of recurrence.

Branchial Cysts in Quito, Ecuador

Introduction  Branchial cleft anomalies are the second most common congenital anomaly in children. However, some lesions may not develop clinically and are not diagnosed until adulthood. The recent literature of branchial cysts (BCs) in the adult population is really scanty. For this reason, we analyzed the clinical and surgical management of the adult population treated for a BC at a tertiary care general hospital. Methods  A retrospective review of the clinical records of all the patients with histological diagnosis of BC who were surgically treated at the Social Security Hospital in Quito, Ecuador, was performed. Fifty-one patients (27 women) with congenital anomalies of the 2 nd (43 patients with cysts) and 3 rd (6 patients with cysts and 2 with fistula) branchial arches were diagnosed and treated. Diagnosis was made on clinical grounds and by computed tomography scan. Results  The 43 patients with a 2 nd branchial cleft cyst underwent complete surgical excision through a wide mid-neck transverse cervicotomy. The 6 cases of 3 rd branchial cleft cyst underwent surgical resection through a lower-neck transverse incision, and the 2 patients with clinical fistula in the lower aspect of the neck were operated on via an elliptical incision around this external fistula opening. Postoperative evolution was uneventful in all patients. Conclusions  Branchial cysts can occasionally be diagnosed in adult patients in the setting of a general hospital population. A correct clinical and imaging assessment was diagnostic in most patients. Complete surgical resection was curative in all our patients, and postoperative complications were exceptional.

Dermatopathology of Cutaneous Cystic Lesions: A Practical Review With Diagnostic Clues and Pitfalls

BACKGROUND

Cystic lesions are common in the daily practice of dermatologists and dermatopathologists, and in most cases, a straightforward diagnosis can be done. Yet, some variants and situations may cause diagnostic problems or carry prognostic and/or systemic implications.

OBJECTIVE

To review the histopathological features of the most frequent cystic lesions, either true cysts or pseudocysts, and provide some clues and pitfalls to bear in mind for troublesome situations such as solid-cystic tumors; uncommon variants; incidental findings; artifactual, reactive, or infectious cavities; cysts as a warning of systemic and hereditary diseases; and malignant cystic tumors, either primary or metastatic.

METHODS

The histopathological diagnostic criteria of most cystic lesions and their potential caveats will be discussed, offering some diagnostic clues.

RESULTS

Cystic lesions of the skin can primarily be classified into true cysts and pseudocysts. The most frequent pseudocysts are sinus pilonidalis and mucin-filled cavities. True cysts can be divided according to their epithelial origin or differentiation into epidermal/pilar cysts, cysts from glandular appendages, and from embryonic remnants. Diagnostic dilemmas and possible pitfalls in cystic lesions are reviewed, offering some keys to solve them.

CONCLUSIONS

Knowledge of the histopathology of cystic lesions contributes to their correct diagnosis, improving the management of patients.

Congenital Midline Cervical Cleft: First Report and Genetic Analysis of Two Related Patients

OBJECTIVES

Congenital midline cervical cleft (CMCC) is a rare congenital anterior neck anatomical anomaly. We present the case of two related patients (grandchild and maternal grandmother) who were both born with a congenital midline cervical cleft along with genetic analysis.

METHODS

Clinical examination of both patients and surgical excision of the grandchild was performed. Genetic analysis with exome sequencing (ES) was conducted for both patients.

RESULTS

Genetic analysis with exome sequencing (ES) revealed apparently novel single nucleotide variants in 66 genes present in both proband and grandmother. Five of these variants are predicted to cause frameshifting in the coding region of the respective genes and truncated proteins (OVGP1, TYW1B, ZAN, SSPO, FOLR3). Two of these genes (TYW1B and SSPO) have homozygous indel mutations in both patients.

CONCLUSIONS

To our knowledge, this is the first case of two related patients with a congenital midline cervical cleft. The results of our genetic analysis reveal potential relevance to CMCC development.

Thyroglossal duct cyst: Factors affecting cosmetic outcome and recurrence

BACKGROUND

Thyroglossal duct cyst (TDC) is the most common congenital abnormality in the neck in children. The purpose of this study was to perform a comprehensive review of all cases of TDC surgically treated at a single institution and to evaluate the factors that influence the rate of recurrence, and the aesthetic outcome of the surgery on follow up.

METHODS

All cases of TDC surgically treated at the Department of Pediatric Surgery at Meyer Hospital from January 2005 to December 2016 were selected. Charts from 248 patients were reviewed and risk factors for recurrence evaluated. A questionnaire was submitted to the patients' parents to determine if postoperative complications were present  and standardized neck pictures were requested, to evaluate the cosmetic result . Microsoft Office Excel 2007 for Windows and Graphpad Prism 6 were used for data management and statistical analysis.

RESULTS

Simple cyst excision and post-inflammatory fibrosis (P < 0.05) were assessed as important risk factors for the recurrence of TDC. Recurrence rate on Sistrunk procedure was 5%. Variables such as post-inflammatory fibrosis before surgery (P < 0.001), the positioning of a drain (P < 0.01) and the development of recurrence (P < 0.001), negatively influenced the cosmetic result. No thyroglossal duct cyst carcinoma and no long-term postoperative complications were observed.

CONCLUSIONS

Recurrence rates were higher in patients who underwent simple cyst excision instead of the Sistrunk procedure, as already reported in literature. Presence of post-inflammatory fibrosis and positioning of the drain at surgery were associated with higher rates of recurrence, as well as worse cosmetic outcome.

Intraoperative injection of combined fibrin sealant and methylene blue dye for surgery of branchial cleft cysts: A case report

Differential diagnosis of a lateral neck mass, especially in paediatric patients, should include branchial cleft cysts (BrCC). It is often difficult to identify and completely resect all cystic components, especially when the lesion becomes infected and/or gigantic. Incomplete excision increases the likelihood of recurrences. We reported a simple technique to facilitate the BrCC resection. Tisseel fibrin glue (FG: Baxter AG, Vienna, Austria) was mixed with methylene blue dye in inverse portion to the cyst size and/or the FG volume before injecting into the cystic lumen. After polymerisation of the dyed glue, the lesion was better visualised and extirpated in toto with the aid of the dye colour and gelatinisation by FG. An up-to-date diagnostic and therapeutic algorithm for BrCC was also presented.

Second branchial cleft anomalies in children: a literature review

Branchial cleft anomalies are the second most common head and neck congenital lesions in children. It may sometimes be a part of branchio-oto-renal (BOR) syndrome, so in patients with branchial cleft anomalies associated with a complaint of auricular deformity or a similar history and findings in other family members, we should take an additional examination to find the possibility of BOR syndrome. Complete excision is essential for good prognosis. For the management of branchial cleft anomalies, various methods have been reported. Endoscopically assisted dissection technique and transoral robot-assisted surgery were used in the management of fistula and allowed excellent visualization of the pharyngeal component of the lesion and a minimally invasive approach. It is essential for the surgeon to fully comprehend the congenital lesions to attain the correct preoperative diagnosis and plan for an appropriate surgical approach to prevent the most common complication and recurrence in these lesions. The following sections discuss the anatomy, common presentation, auxiliary examination, differential diagnosis, the current principles of surgical treatment and prognosis for second branchial cleft anomalies in children, and discussed the branchio-oto-renal syndrome.

Congenital Neck Masses

Congenital neck masses can be a developmental anomaly of cystic, solid, or vascular origin. They can also constitute neoplasms, including malignancies, although this is rare in the pediatric population. The history and examination can help quickly narrow the differential diagnosis. Imaging also plays an essential role in defining the characteristics and likely cause of neck masses. The most common neck masses in young children are thyroglossal duct cysts, branchial cleft anomalies, and dermoid cysts. Also important to consider in the differential diagnosis are solid tumors, such as teratomas, or vascular lesions, such as hemangiomas.

Sublingual cysts of different entities in an infant - A case report and literature review

BACKGROUND

Congenital cysts and fistulas of the neck are common in children, often located in the head and neck area. Belonging to the group of tumor-like conditions, dermoid and epidermoid cysts are dysontogenetic lesions with seldom multiple co-occurrences in infants.

CASE REPORT

We report on a nine-month-old female with a persisting congenital fistula of the tongue. The patient was admitted with acute poor feeding and hypersalivation, which started within the last 24 h. Magnetic resonance imaging detected a fistula of the tongue connected to sublingual cystic lesions. Intraoral surgical removal of three cystic lesions and the fistula was performed under general anesthesia. Histopathological analysis confirmed the coexistence of an epidermoid cyst and two dermoid cysts.

CONCLUSION

Sudden feeding difficulties in combination with dysphagia and tongue displacement in pediatric patients pose an emergency situation that requires prompt diagnostic clarification. A persisting congenital fistula of the tongue is a clear indication of dysontogenetic lesions, including malformations, tumors, and tumor-like lesions. Congenital sublingual cysts are rare in infants, but can be life threatening when present. Surgical excision with histopathological analysis is essential to exclude any form of malignancy and malignant transformation.

5th Congress of WUWHS Abstract book Florence, Italy September 25–29 2016

The abstract book contains the abstracts of keynote lectures, focus sessions, symposia, workshops, AIUC annual meeting, AISLEC annual meeting, EPUAP annual meeting, ETRS special session, sponsor symposia, oral presentations, poster presentations and the subject index.

Transoral robotic excision of a lingual thyroglossal duct cyst

Lingual thyroglossal duct cysts are a rare and potentially difficult to manage tongue base lesion. We report a case of transoral robotic surgical excision of a lingual thyroglossal duct cyst, in an adult patient. A 68-year-old man presented with a large base of tongue mass, with appearance on ultrasound and computed tomography consistent with a lingual thyroglossal duct cyst. We describe the surgical technique for transoral robotic excision of the cyst. The cyst was completely excised, and the patient had a smooth recovery. There has been no recurrence of the cyst. Transoral robotic surgery has several advantages over the conventional surgical approaches in the treatment of lingual thyroglossal duct cysts, including superior visualisation, and the ability of the robotic surgical system to manoeuvre instruments in a confined space. This enables complete excision, preventing recurrence of the cyst whilst also avoiding a neck scar.

Wide anterior neck dissection for management of recurrent thyroglossal duct cysts in adults

OBJECTIVE

Thyroglossal duct cyst recurrence following resection is attributed to anatomical variability and residual thyroglossal ducts. In adults, thyroglossal duct cyst recurrence is extremely rare and a surgical solution is yet to be well explored. This paper describes our approach to the management of recurrent thyroglossal duct cysts and sinuses in adults using a wide anterior neck dissection.

METHOD

A retrospective review was performed to identify adults who underwent a wide anterior neck dissection for recurrent thyroglossal duct cyst management between 1 January 2009 and 1 January 2015.

RESULTS

Six males and one female were included in the series (mean age, 26.4 ± 10.9 years). Recurrence occurred at a mean of 18 ± 9.8 months following primary surgical management (3 patients underwent cystectomy and 4 had a Sistrunk procedure). All patients subsequently underwent wide anterior neck dissection; there was no further recurrence over the 12-month average follow-up period.

CONCLUSION

This paper describes a wide anterior neck dissection technique for the management of recurrent thyroglossal duct cysts or sinuses in adults; this approach addresses the variable anatomy of the thyroglossal duct and is associated with minimal morbidity.

A Rare Case Report of a Child Coexistence Thyroglossal Cyst and Second Branchial Cleft Fistulae

Thyroglossal duct cysts followed by branchial cleft anomalies are the most common congenital neck masses encountered in practice, second branchial cleft cysts and sinuses are the most common type (LaRiviere and Waldhausen in Surg Clin North Am 92(3):583-597, 2012). Although both abnormalities are common individually, but rarely seen associated in same patient as described in our case. Congenitalcervical 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. A synchronous presentation of both type of cyst and fistula in a same child patient is very rare with no such cases reported in literature till date.

Risk-reduction surgery in pediatric surgical oncology: A perspective

OBJECTIVE

A small percentage of pediatric solid cancers arise as a result of clearly identified inherited predisposition syndromes and nongenetic lesions. Evidence supports preemptive surgery for children with genetic [multiple endocrine neoplasia type 2 (MEN2), familial adenomatous polyposis syndrome (FAP), hereditary nonpolyposis colorectal cancer (HNPCC), and hereditary diffuse gastric cancer (HDGC) and nongenetic [thyroglossal duct cysts (TGDC), congenital pulmonary airway malformations (CPAM), alimentary tract duplication cysts (ATDC), and congenital choledochal cysts (CCC)] developmental anomalies. Our aim was to explore the utility of risk reduction surgery to treat and prevent cancer in children.

METHODS

A systematic review of the available peer-reviewed literature on PubMed was performed using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) search strategy, where possible. Search items included "risk reduction surgery", "hereditary cancer predisposition syndrome", "multiple endocrine neoplasia type 2", "familial adenomatous polyposis", "hereditary nonpolyposis colorectal cancer", "hereditary diffuse gastric cancer", "thyroglossal duct cysts", congenital pulmonary airway malformations", "alimentary tract duplication cysts", "malignant transformation", and "guidelines".

RESULTS

We identified 67 articles that met the inclusion criteria describing the indications for prophylactic surgery in surgical oncology. For the genetic predisposition syndromes, 7 studies were related to professional endorsed guidelines, 7 were related to surgery for MEN2, 11 were related to colectomy for FAP, 6 were related to colectomy for HNPCC, and 12 related to gastrectomy for HDGC. Articles for the nongenetic lesions included 5 for techniques related to TGDC resection, 9 for surgery for CPAMs, and 10 for resection of ATDCs. Guidelines and strategies varied significantly especially related to the extent and timing of surgical intervention; the exception was for the timing of thyroidectomy in children with MEN2.

CONCLUSION

Current evidence supporting prophylactic surgery in the management of pediatric cancer predisposition syndromes and nongenetic lesions is best delineated for thyroidectomy to prevent medullary thyroid cancer in children with MEN2 (Strength of Recommendation Grade B/C). Despite the lack of pediatric specific evidence-based recommendations regarding the appropriate extent and timing for risk-reduction surgery for FAP, HNPCC, HDGC and nongenetic anomalies, our review represents an opportunity towards understanding the postgenomic development of these lesions and provides current indications and techniques for preemptive cancer prevention surgery in children.

[Congenital neck mass. Diagnosis and treatment]

Congenital neck masses are a challenge for general practitioners and specialists. Although some of them are diagnosed in utero, most of them remain silent until complications appear in the adult age. The anatomical location, consistency and age are determinants in guiding the possible diagnosis. A midline infrahyoid mass may be a thyroglossal cyst, however a lateral neck mass is more possible to result in a brachial cyst. Complementary imaging studies are essential such as pathological tests like needle aspiration fine needle aspiration (FNA).

Congenital midline cervical cleft: clinical approach to a congenital anterior neck defect

Numerous malformations can affect the anterior part of the neck presenting at birth as a real diagnostic challenge for the pediatrician or the primary care physician who initially evaluate the baby. Congenital midline cervical cleft represents a rare defect of the midline neck, which is sometimes wrongly diagnosed as a thyroglossal duct anomaly, dermoid cyst, branchial cleft anomaly or "birthmark". A prompt clinical diagnosis and surgical treatment during early infancy are essential to ensure both functional and aesthetic outcome. We report a case of a female neonate with a midline cervical cleft diagnosed immediately after birth. The main features of other congenital anomalies of the anterior neck are also discussed referring to their embryologic origin.

Congenital midline cervical cleft

Congenital midline cervical cleft is a rare anomaly that typically presents in the neonatal period as a thin suprasternal vertical band of erythematous skin with a nipple-like projection superiorly, which may exude fluid. We present the clinical and pathophysiologic features and the imaging findings of this uncommon, and rarely described entity in a newborn girl.

Sinus sternoclavicularis: a congenital cervical sinus

We try to characterize a previously rather neglected congenital cervical sinus located in the sternoclavicular area in five children. This sinus showed extension to the left sternoclavicular joint in all patients, so we call this congenital lesion "sinus sternoclavicularis." With knowledge of this congenital lesion, diagnosis can easily be established based on case history and clinical examination; no further radiological tests are required. Surgical excision is the treatment of choice. The chance of recurrence seems to be high because of misinterpretation of the lesion.

Common pediatric head and neck congenital/developmental anomalies

Pediatric head and neck neuroradiology is a broad and complex topic. This article focuses on several of the common and sometimes challenging pediatric head and neck congenital/developmental anomalies physicians may encounter in clinical practice. Although some diagnoses may be evident on physical examination, others may present a diagnostic dilemma. Patients may initially present with a variety of secondary findings. Imaging serves an important role in making a diagnosis, guiding referral, and in some cases even providing treatment options through interventional radiology. Key diagnostic criteria and critical points of interest for each diagnosis are presented.

First branchial cleft anomalies: otologic manifestations and treatment outcomes

OBJECTIVE

This study describes the presentation of first branchial cleft anomalies and compares outcomes of first branchial cleft with other branchial cleft anomalies with attention to otologic findings.

STUDY DESIGN

Case series with chart review.

SETTING

Pediatric tertiary care facility.

METHODS

Surgical databases were queried to identify children with branchial cleft anomalies. Descriptive analysis defined sample characteristics. Risk estimates were calculated using Fisher's exact test.

RESULTS

Queries identified 126 subjects: 27 (21.4%) had first branchial cleft anomalies, 80 (63.4%) had second, and 19 (15.1%) had third or fourth. Children with first anomalies often presented with otologic complications, including otorrhea (22.2%), otitis media (25.9%), and cholesteatoma (14.8%). Of 80 children with second branchial cleft anomalies, only 3 (3.8%) had otitis. Compared with children with second anomalies, children with first anomalies had a greater risk of requiring primary incision and drainage: 16 (59.3%) vs 2 (2.5%) (relative risk [RR], 3.5; 95% confidence interval [CI], 2.4-5; P<.0001). They were more likely to have persistent disease after primary excision: 7 (25.9%) vs 2 (2.5%) (RR, 3; 95% CI, 1.9-5; P=.0025). They were more likely to undergo additional surgery: 8 (29.6%) vs 3 (11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P=.0025). Of 7 persistent first anomalies, 6 (85.7%) were medial to the facial nerve, and 4 (57.1%) required ear-specific surgery for management.

CONCLUSIONS

Children with first branchial cleft anomalies often present with otologic complaints. They are at increased risk of persistent disease, particularly if anomalies lie medial to the facial nerve. They may require ear-specific surgery such as tympanoplasty.