Third branchial cleft anomaly presenting as a retropharyngeal abscess

MRI in Children With Pyriform Sinus Fistula

BACKGROUND

A variety of imaging modalities have been described for the diagnosis of congenital pyriform sinus fistula (CPSF). To date, there have been few MRI reports.

PURPOSE

To evaluate MRI findings of CPSF and interobserver reliability.

STUDY TYPE

Retrospective.

POPULATION

In all, 115 patients aged 23 days to 15.4 years at operation.

FIELD STRENGTH/SEQUENCE

3.0T/axial T₁ -weighted image (T₁ WI)-SPIR, axial T₂ WI, axial T₂ WI-STIR, coronal T₂ WI-SPIR, diffusion-weighted imaging (DWI), axial and coronal gadolinium-enhanced T₁ WI-SPIR.

ASSESSMENT

For each patient, the medical records, including demographics, clinical manifestations, and MRI findings were reviewed. All the MRI studies were interpreted by three radiologists independently.

STATISTICAL TEST

Kendall's W test was made to determine the interobserver reliability of three reviewers for MRI findings.

RESULTS

CPSF occurred on the left side in 104 (90.4%) patients and on the right side in 11 (9.6%) patients. The male-to-female ratio was 59:56. The age at first episode varied from birth to 12.3 years. There was one neonate patient, who presented with a unilocular cystic mass in the left neck. A tunnel-like lesion between the pyriform fossa and the upper pole of the thyroid gland, T₂ high signal behind the cricothyroid joint, thyroid gland involvement, deep neck abscesses or masses were noted in 46 (40%), 93 (80.9%), 96 (83.5%), and 36 (31.3%) patients, respectively. There was excellent interobserver reliability for all the MRI findings, ranging from 0.84 to 1.00.

DATA CONCLUSION

The sinus tract presenting with a tunnel-like lesion goes behind the cricothyroid joint in most cases. For patients presenting with acute suppurative thyroiditis (AST) or neck infection with thyroid gland involvement, the presence of T₂ high signal behind the cricothyroid joint highly suggests the diagnosis of CPSF. MRI is a reliable method for the diagnosis of CPSF.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 2.

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.

Internal Hypopharyngeal Cyst: A Review of Literature

Detailed information on the hypopharyngeal cyst presentation, terminology, classification, diagnosis, management, and possible complication is scarce though it would lead to life-threatening symptoms. This review article, therefore, meticulously presents and analyzes the majority of the pertaining literature. In this context, a particular emphasis has been placed on the embryological development of the branchial arches while discussing each entity that would improve the current understanding of different pharyngeal cyst's pathologies.

Neonatal Presentation of an Air-Filled Neck Mass that Enlarges with Valsalva: A Case Report

Branchial cleft cysts are common causes of congenital neck masses in the pediatric population. However, neonatal presentation of branchial cleft cysts is uncommon, but recognizable secondary to acute respiratory distress from airway compression or complications secondary to infection. We report a 1-day-old infant presenting with an air-filled neck mass that enlarged with Valsalva and was not associated with respiratory distress. The infant was found to have a third branchial cleft cyst with an internal opening into the pyriform sinus. The cyst was conservatively managed with endoscopic surgical decompression and cauterization of the tract and opening. We review the embryology of branchial cleft cysts and current management.

Fourth branchial cleft anomaly: management strategy in acute presentation

OBJECTIVES

Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician's decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the "ultima ratio" treatment to avoid recurrence.

METHODS

We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus.

RESULTS

A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis.

CONCLUSION

Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.

Bilateral pharyngeal apparatus (branchial) sinuses in a set of identical twins--a case report

Defective closure of the pharyngeal apparatus during the second week of gestation results in pharyngeal arch anomalies. Although pharyngeal apparatus (branchial) anomalies are frequently seen, bilateral cases are rare (only 2% to 3%). Bilaterality has a familial predisposition. Our patients, a set of identical twins, presented with bilateral discharging cervical sinuses noticed at 3 months of age. Physical examination was suggestive of bilateral pharyngeal apparatus (branchial) sinuses. Both patients were managed with surgical excision in the same operative sitting. To the best of our knowledge, ours is the first case of bilateral pharyngeal apparatus (branchial) sinuses in a set of identical twins.

Case report: a branchial cleft anomaly presenting as an oropharyngeal mass

Branchial anomalies are common cervical pathologic entities encountered in the field of otolaryngology and are typical in the pediatric and young adult populations. In most cases, these anomalies present as a cyst, sinus, or fistula in a rather stereotypical fashion. When a branchial anomaly deviates from the classic presentation, an improper diagnosis and inadequate management are more likely to occur, leading to an increased recurrence rate. We present a case of a 6-year-old girl with an incidental finding of a right posterior oropharyngeal wall mass, distinctly separate from the tonsillar fossa, which was found on pathologic analysis to be a branchial cleft anomaly. The theories regarding the pathogenesis of branchial anomalies are presented, along with other cases of atypical branchial anomalies.

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

“Anatomy of the abnormal”—a branch of surgical anatomy—deals with relations of an anomaly to surrounding entities. Here, lateral congenital anomalies of the pharyngeal apparatus are examined; their relations to entities of the neck can be explained embryologically. Location of embryonic pharyngeal arches, clefts, and pouches in the adult is presented and terminology of these anomalies (fistulas, sinuses, cysts) is defined. First “cleft and pouch” anomalies relate with the parotid and facial nerve. Second cleft and pouch anomalies course deeply to second arch structures and superficially to third arch structures. Consequently, they relate with hypoglossal and glossopharyngeal nerves and internal and external carotid arteries. Third cleft and pouch anomalies pass deep to third arch entities and superficial to those of the fourth arch and relate with glossopharyngeal, hypoglossal, superior and recurrent laryngeal nerves, and the internal carotid artery. The complicated course of fourth cleft and pouch anomalies brings them into relationship with glossopharyngeal, hypoglossal, superior and recurrent nerves, internal carotid, aorta, and subclavian arteries. Found superficially are veins (external and anterior jugular, common facial, communicating), nerves (transverse cervical, great auricular, mandibular, cervical branches of facial), and relevant spinal nerves (e.g., accessory). Knowledge of these anatomical relations helps prevent anatomical complications.

An infected branchial cyst complicated by retropharyngeal abscess, cervical osteomyelitis and atlanto-axial subluxation

We present a case of a 44-year-old man who visited his general practitioner for recurrent neck swelling, which was found to be a neck abscess. It was aspirated, later recurred, and then surgically excised. Histology was consistent with an infected branchial cyst. Eight months after discharge, the patient presented with a history of progressive neck pain and stiffness and eventually bilateral upper limb weakness. MRI demonstrated a prevertebral abscess complicated by cervical osteomyelitis and atlanto-axial instability. The abscess was drained and appropriate antibiotic treatment was administered. The patient responded well with full recovery of his upper limb strength and resolution of the abscess. However, he had mild persistent neck stiffness.

Management of Congenital Third Branchial Arch Anomalies: A Systematic Review

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

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

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

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

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

A Third Branchial Pouch Cyst Presenting as a Lateral Neck Mass in an Adult

Anomalies of the branchial apparatus occur with some frequency in the adult and pediatric populations. Branchial anomalies are most often derivatives of the first or second pouch. Branchial anomalies involving the third pouch may present as cysts, sinuses, fistulas, and ectopic glands. They are relatively rare, and they respond well to surgical removal. We report the case of a 53-year-old woman who was referred to us for evaluation of a persistent left upper neck mass. The patient had no history of a cervical mass as a child or young adult. The mass was excised uneventfully, and the final pathology revealed a normocellular parathyroid gland and thymic tissue.

Persistencia de tercer arco branquial

The third branquial arch anomalies represent less than 1% of this deformites. The clinical manifestation can be varied althouth the formation of cysts is the commonest one and may appear at any time in life. We report the clinical case of a 7 year old boy with an neck mass. This mass was diagnosed as a branquial cyst. The patologist found a "timic reminescences". We carry out a review of the literature for this pathology.

[Medullary carcinoma of the thyroid gland (sporadic, familial)]

Medullary thyroid cancer (MTC) is uncommon thyroid tumor with specific characteristics which undoubtedly divide this tumor from other thyroid malignancies. Patients with sporadic or hereditary form of MTC differ in clinical presentation, recurrence of the disease and outcome. The aim of study was to establish surgical characteristics of MTC as well as clinical factors that influence surgical treatment. The study group consisted of 68 patients with MTC managed at the Center for Endocrine Surgery between 1987 and 1999. Retrospective analysis included clinical form of the disease, general data, histological and other tumor characteristics. Mean age of the patients were 47.3 years (female/male ratio: 1.5:1). Mean size of tumor was 80.5 cm3, 72.1% patients had tumor greater than 4 cm. in diameter or extrathyroid spread. The majority of patients were in II and III stadium of the disease. Primary operation (at least total thyroidectomy) was performed in 57 (84%) patients. 2(3%) had postoperatively temporally nerve palsy and 7(10.29%) temporally hypoparathyroidism. The overall survival was 46.8 +/- 9.9% after 9 years and 63.6 +/- 7.2% at 5 years. Postoperative calcitonin value is significant predictor of survival/Spearman's coefficient (R = 0.7048)/, worse prognosis is in correlation with high postoperative calcitonin values. The treatment of choice is at least total thyroidectomy and central lymph nodes resection if enlarged lymph nodes are found. Precise operative technique lowers the risk of postoperative complications. Complex approach to the patient with MTC includes all available methods in pre and postoperative evaluation as well as surgeon's knowledge and skill.

Management of anomalies of the third and fourth branchial pouches

Third and fourth branchial pouch anomalies are rare and usually present as lateral neck masses, abscesses or with acute suppurative thyroiditis. An opening in the piriform sinus can be identified in most cases. We present four cases of fourth branchial pouch sinuses, one of a third branchial cyst and discuss our management. Cannulation of the sinus tract at laryngoscopy, followed by complete surgical excision, via a modified oblique thyrotomy above the cricothyroid joint after detaching the inferior constrictor was used to treat the fourth branchial pouch anomalies. This surgical approach adequately exposes the piriform sinus apex and also affords protection to the recurrent laryngeal nerve. The third pouch cyst and tract were excised at the level of the thyrohyoid membrane. There were no complications or recurrences.

Infected branchial cleft cyst due to Bordetella bronchiseptica in an immunocompetent patient

A healthy 23-year-old man with fever and a tender mass in his right anterior neck was found to have a branchial cleft cyst infected with Bordetella bronchiseptica. Initial testing suggested a Brucella species, but further laboratory testing identified the organism definitively. B. bronchiseptica infection in healthy adults is an unusual event.