Congenital cysts and fistulas of the neck

Preferred diagnostic methods of pyriform sinus fistula in different situations: A systematic review

PURPOSE

Pyriform sinus fistula (PSF) diagnosis is often easily delayed and incorrect. Diagnostic values of modalities vary in different situations. The aim of this study was to recommend optimal schemes for diagnosing PSF at different ages and infection stages.

METHODS

A search of PubMed, Embase, Cochrane Library, and CBM databases was conducted to identify articles written in Chinese and English concerning PSF diagnosis using keywords: "pyriform sinus fistula", "diagnosis", and relevant synonymous terms. Quality assessment was performed using the Joanna Briggs Institute (JBI) levels of evidence and critical appraisal checklist tool.

RESULTS

111 studies describing 3692 patients were included. The highest true positive rate (TPR) of ultrasonography was 66.67 % in adult cases. Computed tomography (CT) yielded a good TPR (approximately 73 %) in both neonatal and adult patients, and contrast-enhanced CT (84.21 %) was better in adult patients. Most children cases could be accurately diagnosed by barium swallow (BS) examination which was significantly different in acute and non-infection stages (AIS, NIS). Magnetic resonance imaging (MRI) produced a nice TPR in fetal cases (69.23 %) and neonatal cases (54.44 %). Laryngoscopy was also affected by infection stages. TPR of gastroscopy (GS) was the highest in children (86.36 %) and adult cases (87.50 %).

CONCLUSION

For fetal cases suspected of PSF, an MRI is recommended. MRI or CT is preferred for neonatal cases regardless of infection stages. Children and adult patients are advised to undergo GS during NIS or AIS, while BS is suggested for NIS. Contrast-enhanced CT can also diagnose adults with PSF in AIS.

A Neck Mass of Thymic Origin in a Pediatric Patient

In this study, we present the case of a 10-year-old boy with a left-sided neck mass. Although most neck masses in children are non-cancerous, their etiology can be complex, especially in neck masses of congenital origin. The workup of a pediatric neck mass includes imaging and cytopathology. In this case, the histopathology of the excised mass revealed thymic tissue, which helped establish the diagnosis of a thymopharyngeal duct cyst. Thymophayngeal duct cysts, although rare, can be diagnosed preoperatively by characteristic tapering toward the mediastinum. Cytopathology may demonstrate Hassall corpuscles. These unique features can help disentangle the differential diagnoses, which commonly include thyroglossal duct cysts, venolymphatic malformations, and branchial cleft cysts.

Fourth Branchial Anomalies: Diagnosis, Treatment, and Long-Term Outcome

Introduction: Fourth branchial anomalies, the rarest among anomalies of the branchial apparatus, often present diagnostic and therapeutic challenges. We evaluated the clinical presentation and radiographic features, the treatment and the long-term outcome of patients in this setting.

Patients and Methods: Of 12 patients treated in the University Hospitals Leuven from 2004 until 2020, 12 variables were collected: date of birth, gender, age of onset of the symptoms, age at final diagnosis, presentation, laterality, previous procedures, diagnostic tools, treatment (open neck surgery, endoscopic laser excision, or combination), complications, recurrence, and period of follow-up. Descriptive statistics were calculated and results were compared to the existing literature.

Results: The most common clinical manifestations were recurrent neck infections with and without abcedation. Definitive diagnosis using direct laryngoscopy, visualizing the internal sinus opening, was possible in all patients. A CT study revealed the typical features of fourth branchial anomalies in seven patients out of nine, an ultrasound study in five out of nine patients. All patients underwent open neck surgery. If this was insufficient, secondary endoscopic laser resection of the ostium at the apex of the piriform sinus was performed (n = 4). In eight patients a thyroid lobectomy was needed for safe complete resection. Postoperative complications were minimal and at long-term, none of the patients showed further recurrence. Average time of follow-up was 8.6 years.

Conclusions: Direct laryngoscopy and CT are the most accurate diagnostic tools. Our recommended treatment schedule consists of complete excision of the sinus tract by open neck surgery as the primary treatment because this ensures the best results. In case of recurrence afterwards, endoscopic laser resection of the pharyngeal ostium solved the problem.

Prenatal Diagnosis of Third and Fourth Branchial Apparatus Anomalies: Case Series and Comparison with Lymphatic Malformation

BACKGROUND AND PURPOSE

Third and fourth branchial apparatus anomalies are rare congenital anomalies. The purpose of this study was to investigate imaging features of these lesions on fetal MR imaging in comparison with lymphatic malformations, the major competing differential diagnosis in these cases.

MATERIALS AND METHODS

A retrospective review of our institutional fetal MR imaging database between 1997 and 2019 resulted in 4 patients with confirmed third and fourth branchial apparatus anomalies and 14 patients with confirmed lymphatic malformations. The imaging features were reviewed by consensus, and the Fisher exact test was used to evaluate statistically significant differences between these 2 populations.

RESULTS

Four cases of third and fourth branchial apparatus anomalies were imaged at 29 weeks 1 day (range, 23 weeks 1 day to 33 weeks 4 days). All 4 cases demonstrated unilateral, unilocular cysts without reduced diffusion or hemorrhage and a medially directed beaked contour that tapered between the spine and airway at the level of the piriform sinus. Compared with 14 cases of fetal lymphatic malformations imaged at 27 weeks 6 days (range, 21 weeks 3 days to 34 weeks 6 days), third and fourth branchial apparatus cysts were significantly more likely to be unilocular (P < .005) and to have a medially beaked contour (P < .005). The combination of features of unilateral, unilocular, and medially beaked contour was observed only in the fetuses with third and fourth branchial apparatus cysts (P < .001).

CONCLUSIONS

The presence of a left-sided unilocular cyst with a medially beaked contour tapering at the level of the piriform sinus suggests the diagnosis of third and fourth branchial apparatus anomaly. Accurate diagnosis in the prenatal period allows proper counseling, genetic work-up, and treatment, potentially sparing patients from recurrent infections and associated morbidity.

Misdiagnosis of asymptomatic intrathyroidal pyriform sinus fistula: a case report

Pyriform sinus fistula is uncommon and easily misdiagnosed. Most reported cases occur in children and are associated with either acute suppurative thyroiditis or deep neck infection. Asymptomatic pyriform sinus fistula is difficult to diagnose because it can manifest as an incidental thyroid nodule with highly suspicious malignant features on ultrasonography. The patient was a 41-year-old man with asymptomatic thyroid nodules incidentally detected on ultrasonography. Surgery was performed under the suspicion of thyroid cancer. Pathology findings revealed multiple cystic walls lined by ciliated columnar cells with stratified squamous epithelial cysts in a background of inflammatory and lymphoid cells. Barium swallow examination performed 2 weeks later revealed a sinus tract measuring 1.8 cm that arose from the apex of the left pyriform sinus. The diagnosis and management of pyriform sinus anomalies are challenging. The majority of physicians, including some otolaryngologists, lack an understanding of the disease, which should be considered one of the important differential diagnoses of neck masses. Barium swallow examination, ultrasonography, computed tomography, and laryngoscopy are useful to diagnose this condition.

Ectopic Cervical Thymus: A Common, yet Rarely Symptomatic Pediatric Neck Mass

Ectopic thymic tissue is an unusual finding that is generally asymptomatic. We present a case series of five pediatric patients with cervical ectopic thymuses. In two patients, the ectopic thymic tissue was symptomatic, and in three patients, it was an incidental finding. We highlight the need to include this anomaly in the differential diagnosis for a pediatric neck mass. We also propose observation, rather than surgical excision, as the treatment of choice for asymptomatic cervical ectopic thymus.

Two Different Tracts and Origin of Pyriform Sinus Fistula

OBJECTIVE

Suppurative acute thyroiditis is caused by pyriform sinus fistula (PSF), and PSF frequently elicits deep neck abscess. However, complete fistulectomy is the ideal management of PSF, and studies on surgical findings of PSF are exceedingly rare. This study aimed to reveal the origins of PSF, each route, and clinical presentation.

METHODS

This is a multicenter study. We have conducted 19 complete fistulectomies of PSF in Japan, analyzed routes of the fistulas, estimated the origins, and investigated their histological and clinical findings.

RESULTS

No recurrence was observed in all cases. Five of 12 cases showed thymic and/or parathyroid tissues around the fistulas, passing inside the inferior horn of thyroid cartilage, were regarded as having 3rd pouch origin, and tended to have low frequency of severe deep neck abscess. The remaining 7 cases originated from the 4th pouch running outside of the horn and showed frequent severe infection.

CONCLUSION

PSF have 2 different routes depending on their generation and may present different clinical manifestations.

Application of Gastroscopy in the Diagnosis of Congenital Pyriform Sinus Fistula in Children

Objective: The aim of this study was to explore the diagnostic value of gastroscopy under local anesthesia for congenital pyriform sinus fistula (CPSF). Methods: This research was a diagnostic study. Patients received gastroscopy under local anesthesia to diagnose CPSF, and suspension laryngoscopy under general anesthesia was performed 2 days after gastroscopy. Various conditions of the internal opening of CPSF were then recorded. Patients were grouped according to lesion sides, age, time after the inflammation subsided, and history of previous surgery. The sensitivity, specificity, area under the receiver operating characteristic curve (AUC), accuracy, and positive and negative predictive values of gastroscopy were compared between the groups. Results: A total of 48 patients were recruited in this study, and no patients had severe gastroscopy-related complications. The diagnostic values of gastroscopy in 41 cases (85.4%) were consistent with suspension laryngoscopy. The sensitivity of gastroscopy was 86.4%, the specificity was 75%, the AUC was 0.807, the positive prediction rate was 97.4%, the negative prediction rate was 33.3%, the accuracy rate was 85.4%, and the diagnostic odds ratio (DOR) was 2.1. The kappa consistency test results had statistical significance (P = 0.0026, kappa = 0.3913). The diagnostic value of gastroscopy was better for the patients with inflammation subsiding for more than 4 weeks (P < 0.0001). Conclusion: Gastroscopy under local anesthesia is a safe, effective, reliable and novel diagnostic method for CPSF, and it is especially recommended as a diagnostic method for the patients with inflammation subsiding for more than 4 weeks.

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.

Optimal Timing of the First Barium Swallow Examination for Diagnosis of Pyriform Sinus Fistula

OBJECTIVE

Observation of a sinus tract during a barium swallow examination is important for the diagnosis of pyriform sinus fistula; however, to our knowledge, no reports have existed regarding the optimal timing of the examination in relation to the onset of symptoms. The purpose of this study was to compare the timing of the examination, patient age, the number of inflammatory episodes that occurred before the examination, and the barium concentration used for examinations with true-positive results versus those with false-negative results for the diagnosis of pyriform sinus fistula.

MATERIALS AND METHODS

Twenty-three children with pyriform sinus fistula were included. The timing of the examination, patient age, the number of the inflammatory episodes that occurred before examination, and the barium concentration used were compared between examinations with true-positive results and examinations with false-negative results, by use of the Mann-Whitney U test.

RESULTS

The examination had true-positive results for 60.9% (14/23) of patients and false-negative results for 39.1% (9/23) of patients. The mean (± SD) interval since the onset of symptoms was significantly shorter for patients with false-negative examination results than for those with true-positive examination results (26.33 ± 21.17 days vs 48.57 ± 17.67 days; p = 0.020). By 6 weeks after the onset of symptoms, more than half of the examinations had false-negative results. No significant difference in patient age (p = 0.238) or number of previous inflammatory episodes (p = 0.431) existed between examinations with true-positive and false-negative results; however, a significant difference was noted in the mean barium concentration used (88.57% ± 31.53% vs 52.86% ± 18.68% weight/volume, respectively; p = 0.014).

CONCLUSION

Barium swallow examinations with false-negative results were significantly more likely when the examination was performed soon after the onset of symptoms. Therefore, early first examinations would not be recommended for the diagnosis of pyriform sinus fistula, especially in terms of radiation exposure. A higher barium concentration may be useful.

Paediatric neck ultrasonography: a pictorial essay

The neck structures are located very superficially and are therefore easy to explore by ultrasound examination. Ultrasonography is crucial for the detection of neck pathologies in children. High-frequency probes (10-15 MHz) are used for the ultrasound examination on the patient lying in supine decubitus and with their neck stretched out. The outcome of the exam depends mainly on the child's cooperation-hence the need for warm sonographic gel and a comfortable cushion to place under the patient's shoulders. The complete scan of the neck includes the evaluation of the thyroid and salivary glands and the vascular structures as well as the lymph node analysis. In children and adolescents, the thymus is often visualised in the supraclavicular and jugular scans. It appears as a structure, usually hypoechoic, with thin hyperechoic straps, though echogenicity increases with age. In this pictorial essay, the main pathological conditions of the neck in paediatric age will be examined, such as thyroid dysgenesis, thyroiditis, thyroid nodules, lymphadenopathies, cystic lesions, haemangiomas and vascular malformation, cervical thymus, fibromatosis colli and pilomatrixoma.

Branchial cleft cysts: a pictorial review

Cystic masses of the neck may represent a wide variety of pathological conditions. Among these, branchial anomalies are the commonest paediatric congenital lesions of the head and neck. This article intends to review this condition under the same headings, as well as facilitate their diagnosis with the help of appropriate radiological findings of patients diagnosed with these anomalies. In order to make an accurate diagnosis, it is imperative to have an idea about the possible differentials, and the normal embryological development of the branchial arches, as well as their anomalies, in the form of sinuses, fistulae, and cysts, with their features and subtypes. The medical history of the patient and clinical manifestations helps in suspecting branchial cleft cysts; confirmatory imaging modalities include computed tomography, magnetic resonance imaging, ultrasonography, and fine-needle aspiration. The mainstay of management is usually by surgical excision. The location, clinical picture, and radiological correlation, along with a strong degree of suspicion for the condition, facilitates the diagnosis of this relatively common embryological anomaly.

A Clinicopathologic Series of 685 Thyroglossal Duct Remnant Cysts

The clinical features of thyroglossal duct remnant cysts (TGDC) have been well described, however the histopathologic aspects of these lesions have not been addressed in a detailed manner. In particular, there has been no large community practice based series evaluating TGDC histologically compared with management outcomes. A retrospective review of all TGDC diagnosed between 2005 and 2015 was performed. Six hundred eighty-five patients were identified (344 males; 341 females). Age at presentation was bimodal (first and fifth decades) and ranged from 0.8 to 87 years (mean 31.3 years). Males predominate in children (150:111); females in adults (230:194). Patients presented most frequently with a mobile midline neck mass in an infrahyoid location. An associated skin fistula (n = 67) was twice as common in pediatric as adult patients. The average cyst size was 2.4 cm (range 0.4-9.9 cm) by imaging studies and 2.6 cm (range 0.2-8.5 cm) by pathologic examination; pediatric patients had smaller cysts (mean 2.1 cm) than adults (mean 2.8 cm). Histologically, 257 (38 %) TGDC were lined by respiratory epithelium alone, 68 (10 %) squamous epithelium alone, 347 (51 %) exhibited both respiratory and squamous epithelium, and 13 (1 %) had no identifiable epithelial lining. Four hundred eighty-four (71 %) TGDC had associated thyroid gland tissue present within the cyst wall (n = 282), skeletal muscle (n = 71), adipose tissue (n = 34), or a combination of these sites (n = 97). The hyoid bone was identified in 647 (grossly and/or histologically), and absent in 38. Surgical management consisted of Sistrunk procedure (n = 647), cystectomy (n = 31), or thyroidectomy/thyroid lobectomy (n = 7). Treatment related complications were observed in 6 patients, which included vocal cord damage, seroma, and hematoma. Recurrences developed in 20 (3 %) patients, 14 of whom were managed initially by cystectomy. Papillary thyroid carcinoma was identified in 22 (3.2 %) TGDC. In summary, TGDC show a bimodal peak in the 1st and 5th decades, commonly presenting as a midline cervical lesion below the hyoid bone, associated with a skin fistula in 10 %. Histologically TGDC are most commonly lined by a combination of respiratory and squamous epithelium. Thyroid gland tissue is identified in 71 % of cases (0.45 cm mean size), although not limited to the cyst wall, but present in the surrounding soft tissues. Rare TGDC may harbor malignancy (3.2 %). TGDC are most effectively managed by Sistrunk procedure rather than excision, which carries low rates of complications (1 %) and recurrence (3 %).

Congenital midline cervical cleft: A retrospective case series of 8 children

OBJECTIVES

Congenital midline cervical cleft is a rare developmental abnormality of the ventral neck of unclear etiology. It consists of a midline skin defect. This study reports a case series of 8 patients with congenital midline cervical cleft.

METHODS

Retrospective review chart including all children referred with congenital midline cervical cleft over 5 years in tertiary center. The study was conducted to determine the presence of associated malformations, to specify the cleft pathology, to analyze the nature of associated cysts, and to discuss surgical procedure.

RESULTS

Eight patients ranged from 3 days to 5 years. Two had an associated cervical midline cyst, 3 had a significant micrognatia. Pathological observations were in favor of a branchial origin. There was no recurrence of cervical contraction after a mean follow-up of 20 months.

CONCLUSION

Congenital midline cervical cleft is a rare and generally isolated congenital malformation. It does not require either extensive assessment or specific genetic. Described associated cysts might be part of the cleft and not bronchogenic or thyroglossal cysts. Early surgical excision reduces cervical contracture, but linear or Z-plasty closure is still debated.

Distribution of branchial anomalies in a paediatric Asian population

INTRODUCTION

The objective of the present study was to review the distribution and incidence of branchial anomalies in an Asian paediatric population and highlight the challenges involved in the diagnosis of branchial anomalies.

METHODS

This was a retrospective chart review of all paediatric patients who underwent surgery for branchial anomalies in a tertiary paediatric hospital from August 2007 to November 2012. The clinical notes were correlated with preoperative radiological investigations, intraoperative findings and histology results. Branchial anomalies were classified based on the results of the review.

RESULTS

A total of 28 children underwent surgery for 30 branchial anomalies during the review period. Two children had bilateral branchial anomalies requiring excision. Of the 30 branchial anomalies, 7 (23.3%) were first branchial anomalies, 5 (16.7%) were second branchial anomalies, 3 (10.0%) were third branchial anomalies, and 4 (13.3%) were fourth branchial anomalies (one of the four patients with fourth branchial anomalies had bilateral branchial anomalies). In addition, seven children had 8 (26.7%) branchial anomalies that were thought to originate from the pyriform sinus; however, we were unable to determine if these anomalies were from the third or fourth branchial arches. There was inadequate information on the remaining 3 (10.0%) branchial anomalies for classification.

CONCLUSION

The incidence of second branchial anomalies appears to be lower in our Asian paediatric population, while that of third and fourth branchial anomalies was higher. Knowledge of embryology and the related anatomy of the branchial apparatus is crucial in the identification of the type of branchial anomaly.

Hairy polyp of the supratonsillar fossa causing intermittent airway obstruction

Introduction Dermoids frequently called “hairy polyps” and their nature have not been completely clarified.

Objectives To discuss the unusual presentation, symptoms, incidence, histology, and perioperative management of hairy polyps in the light of a case and current literature.

Resumed Report A 3-year-old boy presented with intermittent respiratory distress since birth. Oropharyngeal examination revealed a nasopharyngeal mass originating from the supratonsillar fossa. The mass was so mobile that it moved between the oropharynx and the nasopharynx during swallowing. The radiologic and pathologic examinations confirmed the mass as a hairy polyp.

Conclusion In a pediatric age group with airway obstruction, hairy polyps of the oropharyngeal region must also be included in the differential diagnosis.

Residual fistula of fourth branchial arch anomalies and recurrent left-side cervical abscess: clinical case and review of the literature

Congenital fourth branchial arch anomalies are uncommon entities. Most of these anomalies are diagnosed in childhood. The majority of cases occur on the left side. The clinical presentation of these anomalies varies with age. A respiratory distress is the usual clinical presentation in neonates, cervical cutaneous fistulas in late childhood or acute suppurative thyroiditis. Multiples diagnostic options have been described with different modalities of treatment. The majority of cases of fourth branchial arch anomalies are described only in case reports. We report a clinical case of recurrent cervical abscess in a young woman due to a residual fistula of fourth branchial arch.

Paediatric neck masses at a University teaching hospital in northwestern Tanzania: a prospective analysis of 148 cases

Background

Pediatric neck masses are one of the common surgical conditions presenting to the pediatric surgical wards and clinics in many centers worldwide. There is paucity of published information regarding pediatric neck masses in Tanzania and the study area in particular. This study determines the etiology, clinico-histopathological patterns and treatment outcome of pediatric neck masses and to identify predictors of outcome in our local setting.

Methods

This was a prospective cross-sectional hospital based study done in children aged ten years and below with neck masses for a five months period. Statistical data analysis was done using SPSS version 17.0.

Results

A total of 148 patients were studied. Their ages ranged from 2 months to 10 years (median 3 years). The male to female ratio was 2.5:1. Inflammatory lesions were the most frequent cause of neck masses accounting for 43.9% of cases. The median duration of illness was 2 years. Except for the neck mass, 72 (48.6%) of the children had clinically stable health condition on presentation. The posterior triangle was commonly involved in 118 (79.7%) patients. eight (5.4%) were HIV positive. The majority of patients (95.9%) were treated surgically. Postoperative complication rate was 30.4% and surgical site infection was the most frequent complication in 37.5% of cases. The median length of hospital stay was 10 days and was significantly longer in patients with malignant masses and those with surgical site infection (p <0.001). The overall mortality rate in this study was 8.1% and it was significantly associated with malignant masses, associated pre-existing illness, late presentation, HIV positivity, low CD 4 count, high ASA class and presence of surgical site infections (p <0.001). The outcome of patients on discharge was excellent as more than 90% of patients were successfully treated and discharged well.

Conclusion

Pediatric neck masses are among the most common causes of paediatric surgical admissions and pose a diagnostic and therapeutic challenge in our setting. We advocate early surgical consultation and thorough and timely histopathological examination of neck masses in children.

Epidermoid cysts in head and neck: our experiences, with review of literature

Epidermoid cysts are benign lesions, characterized by cystic spaces lined by simple squamous epithelium (epidermoid cyst), containing skin adnexa ("true" dermoid cyst) or tissues of all three germ layers (teratoid cyst). Head and neck constitute ~7% of all cases of epidermoid and dermoid cysts. There is often a diagnostic dilemma with the more common cystic lesions of this region. A retrospective case-series study of histologically proved epidermoid cysts in the head-neck region, from February 2008 to January 2011, in the Department of Otorhinolaryngology and Head-Neck Surgery of a tertiary Government teaching hospital in eastern India. The diagnosis was reached by fine needle aspiration cytology FNAC and subsequent histopathology where feasible. Necessary imaging was done for evaluation and management. A total of 28 cases were analyzed. 5 were female, with a male: female ratio of 4.6. Age range was from 2 to 60 years (mean = 30). Excision was the preferred treatment in 20 cases (71.4%). Various sites like the submandibular region (5), pinna (5), sublingual region (1), periorbital (6), suprasternal (6), along the anterior border of sternocleidomastoid (1) and glabella (3) were involved, along with an iatrogenic implantation epidermoid cyst in a tracheostomy scar. Some of the interesting cases presenting with clinical dilemma have been emphasized. Epidermoid cysts are relatively less common in the head-neck region, hence are liable to be misdiagnosed. In this case-series, few cases presenting with enough elements of confusion and dilemma are discussed with overall analysis and review of the related literature.

Pediatric neck masses

The majority of neck masses in the pediatric population are congenital or inflammatory in origin requiring a thorough understanding of embryology and anatomy of the cervical region. However, malignancy must always be ruled out as they represent 11%-15% of all neck masses in the pediatric population. The initial history and physical are of utmost important to correctly work-up and eventually diagnose the lesion. This article addresses many aspects of the workup, diagnosis and eventual proper surgical or medical management of pediatric neck masses.

Preauricular angioleiomyoma

Preauricular masses are commonly seen in the otology clinic. Excisional biopsy is essential for diagnosis, and treatment is necessary to reduce the risk of malignancy and for cosmetic purposes. We recently treated a rare case of angioleiomyoma of the preauricular area. Angioleiomyoma is a benign tumor arising from smooth muscle within blood vessel walls. These tumors can arise anywhere in the body; however, they are usually found in the lower extremities and present as a painful mass. Angioleiomyoma of the preauricular area in an elderly person is rare, and only a few cases have been reported. Here, we report the case of an 85-year-old male patient with angioleiomyoma of the preauricular area and provide a literature review.

The fourth branchial complex anomaly: a rare clinical entity

Fourth branchial pouch anomalies are rare congenital disorders of the neck and are a consequence of abnormal development of the branchial apparatus during embryogenesis. Failure to appropriately recognize these anomalies may result in misdiagnosis, insufficient treatment, and continued recurrence. Here, we present an unique presentation of two cases, describe their diagnosis, clinical course, and management, and review the literature regarding these interesting 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.

Presentations and management of thyroglossal duct cyst in children versus adults: a review of 106 cases

OBJECTIVE

The objective of this study was to determine the clinical presentations and management of thyroglossal duct cyst (TDC or thyroglossal tract remnant [TTR]) between children and adults and evaluate risk factors associated with recurrence after surgery for TDCs.

STUDY DESIGN

A retrospective study of all patients with TDCs managed in our department from January 1998 through April 2008 was performed. All records were reviewed for age and sex, sizes and locations of cysts, diagnostic methods, surgical management, recurrences, and complications. Differences between children and adults and risk factors associated with recurrence were evaluated.

RESULTS

A total of 106 patients (47 children and 59 adults) were treated for TDC. Of the children, 57.4% were male and 42.6% were female, whereas 50.8% of the adults were male and 49.2% were female. There were no significant differences in sex in either group (P > .49). The average age was 7.0 ± 4.2 years in children and 36.0 ± 18.0 years in adults, which demonstrates a bimodal distribution. Adults were significantly more likely than children to present with a complaint other than mass or infection (P < .01), including pain, dysphagia, dysphonia, and fistula formation. There was no significant difference in frequency of location between the adults and children. In this article, 94.9% (56/59) of the adults and 87.2% (41/47) of the children underwent a Sistrunk operation, whereas the others underwent cyst excision. There were 2 recurrences among adults and 3 among children, all of whom presented with an infected neck mass and were treated with a second Sistrunk procedure. The recurrence rates and complications between children and adults were not significantly different.

CONCLUSIONS

The incidence of TDC was equal in males and females and had a bimodal distribution with similar incidence in children and adults. Adults were significantly more likely than children to present with a complaint other than mass or infection. The Sistrunk procedure is recommended as the main choice of treatment. Cyst infection may have a role in recurrence.

Endoscope-assisted intra-oral resection of the external thyroglossal duct cyst

OBJECTIVE

Surgical removal of a thyroglossal duct cyst (TGDC) and its tract is usually accomplished through an external neck incision, including the removal of the middle part of hyoid bone and a block of tissues extending to the foramen cecum. However, this procedure inevitably results in neck scarring. We implemented a modified approach to TGDC removal in a 28-year-old woman through the floor of the mouth using an endoscope system.

CASE REPORT

Here, we describe the detailed procedure of the endoscope-assisted intra-oral resection for TGDC. The total operative time was 130 minutes. The patient complained of swelling and pain in the floor of the mouth for 2 days, but did not require any intervention. Follow-up imaging studies confirmed no recurrence (18 months) without any sequelae, and the patient was satisfied with her surgical outcome.

CONCLUSION

The intra-oral approach through the floor of the mouth is a technically feasible alternative surgical option that allows for complete removal of a TGDC without the neck scar.

[The cysts and fistulas of the neck in material of Otolaryngology Department of Rydygier District Hospital in Cracow]

The retrospective study describes 118 patients treated for congenital cysts and fistulas of the neck between 1997 and 2007 in ORL Department of Rydygier District Hospital in Cracow. Malformation was divided into midline and laterocervical region anomalies. Malformation of midline included thyreoglossal duct and dermoid cyst. The most common malformation of laterocervical were cysts followed by fistulas. The theory of development, method of diagnosis and operative management were presented. Complication and recurrences were rare. Proper differential diagnosis and radical operation led to successful cure.

Management of congenital fourth branchial arch anomalies: a review and analysis of published cases

BACKGROUND/PURPOSE

Congenital fourth branchial arch anomalies are uncommon entities, heretofore described only in case reports, affecting primarily children, and typically presenting as a cervical inflammatory process. The aim of the study was to collect appropriate data on the diagnosis, treatment, and outcome of this condition and to suggest guidelines for its management.

METHODS

We conducted a structured review of the literature for cases explicitly identified as congenital fourth branchial arch anomalies or meeting anatomical criteria for this condition. We computed descriptive statistics and performed several post hoc 2-way comparisons of subgroups of cases.

RESULTS

We located and critically evaluated 526 cases. Fourth arch anomalies were usually located on the left (94%) and generally presented as acute suppurative thyroiditis (45%) or recurrent neck abscess (42%). Barium swallow and direct laryngoscopy were the most useful diagnostic tools. Treatment options differed mainly in recurrence rates: incision and drainage, 89%; open neck surgery and tract excision, 15%; endoscopic cauterization of the sinus tract opening, 15%; and open neck surgery with partial thyroidectomy, 8%. Complications after surgery occurred primarily in children 8 years or younger.

CONCLUSION

Fourth arch anomalies are more common than once thought. Treatment of these disorders with repeated incision and drainage yields high rates of recurrence; thus, complete excision of the entire fistula tract during a quiescent period appears preferable. Combining this surgery with partial thyroidectomy may further decrease recurrence rates. Complications can likely be minimized by using antibiotic treatment of acute infections or endoscopic cauterization in children 8 years or younger, and delaying open neck surgery.

An unusual presentation of a fourth pharyngeal arch (branchial cleft) sinus

Fourth pharyngeal arch (branchial cleft) sinuses and fistulas are a rare cause of recurrent neck abscesses presenting in the first 2 decades of life. Because they are uncommon, the diagnosis and subsequent treatment can be delayed, even with proper radiographic imaging and clinical evaluation. This case illustrates a life-threatening presentation of a ruptured fourth branchial cleft sinus with extravasation into the mediastinum, chest, and abdomen.

Cervical thymic remnants in children

OBJECTIVE

Define the clinical presentation, diagnostic value of preoperative imaging, surgical management, and outcomes of treatment of congenital cervical thymic remnants in children.

DESIGN

Retrospective cohort.

SETTING

Single tertiary care institution.

PATIENTS

20 children who underwent excision of cervical thymic remnant, 1975-2006.

MAIN OUTCOMES MEASURED

Utility of preoperative imaging to diagnose cervical thymic anomalies; success of surgical treatment of cervical thymic remnants.

RESULTS

A total of 20 children were identified, with an average age of 6.98+/-5.63 years. All ectopic thymus tissue was found in the embryonic distribution area associated with the third branchial pouch. Fourteen patients underwent excision of a cystic ectopic thymus. Four of these patients exhibited lesions isolated to the cervical region, and 10 patients displayed lesions involving cervicomediastinal areas. Six patients underwent excision of solid ectopic cervical thymus, and each of these was an unanticipated mass encountered during surgical dissection for other procedures. 83% of patients with solid ectopic cervical thymus presented at age 3 or younger. Physical exam and preoperative imaging correctly diagnosed thymic remnants in 15% patients. Resection of thymic remnants was successful in all patients, and there were no recurrences.

CONCLUSIONS

Though rare, thymic remnants should be considered in the differential diagnosis of masses presenting in locations associated with derivatives of the third branchial pouch. Though preoperative imaging is helpful in identifying the extent of these lesions, congenital thymic remnants prove difficult to diagnosis radiologically. Surgical excision is the diagnostic and therapeutic treatment of choice in the management of cervical thymic remnants.

Congenital Familial Bilateral Branchial Tracts: A Rare Case

The embryologic development of the head and neck is directed by an ensemble of numerous genes. Embryologic malformations of the head and neck are rare. When they do occur, the most common are thyroglossal duct cysts and branchial anomalies. Most malformations are apparent at birth. Complete excision at an early stage is recommended to prevent complications such as infection. We describe an extremely rare case of bilateral branchial tracts in which there was evidence of a genetic etiology. To the best of our knowledge, this is the first case of familial bilateral branchial tracts to be described in the literature.

Congenital neck masses: a descriptive retrospective study of 252 cases

PURPOSE

This retrospective study was conducted to analyze congenital neck masses in Jordanians compared with international findings.

PATIENTS AND METHODS

The records of patients with congenital neck masses between 1991 and 2002 were retrieved from the Department of Pathology, Jordan University of Science and Technology, and analyzed for age, gender, location, clinical features, and treatment.

RESULTS

Within the 12-year period of the study, a total of 2,063 neck mass lesions were found; of these, 252 (12%) were congenital masses. These cases were distributed into 166 (66%) midline, 55 (22%) lateral, and 31 (12%) entire neck masses. The most frequent mass was thyroglossal duct cyst (fistulas) (53%), followed by cysts (fistulas) of the branchial apparatus (22%), dermoid cysts (11%), hemangiomas (7%), and 1ymphangiomas (6%). The majority of branchial arch anomalies (85%) were of the second arch. The mean age of patients was 16 years, with the greatest number of cases (38%) in the first decade. The male-to-female ratio was 1:1.2, with most lesions affecting females. The majority of lesions presented with painless neck swelling, and all lesions were surgically excised.

CONCLUSIONS

The overall frequency and age distribution of congenital neck masses in northern Jordanians are similar to international findings. However, the gender distribution and relative frequency of individual types of neck masses are somewhat different from those in other countries. These differences may be attributed to genetic and geographic differences.

Thyroglossal duct cyst: personal experience and literature review

The thyroglossal duct cyst [TDC, or thyroglossal tract remnant (TTR)] is a well recognized developmental abnormality which arises in some 7% of the population. As a consequence, it represents the most common type of developmental cyst encountered in the neck region. It typically presents as a mobile, painless mass in the anterior midline of the neck, usually in close proximity to the hyoid bone. Less often, TDCs may present with signs and symptoms of secondary infection, or with evidence of a fistula. While TDCs are most often diagnosed in the pediatric age group, a substantial minority of patients with TDCs are over 20 years of age at the time of diagnosis. The standard surgical approach to TDC, encompassing removal of the mid-portion of the hyoid bone in continuity with the TDC and excision of a core of tissue between the hyoid bone and the foramen cecum, dates back to the late 19th and early 20th centuries and is often referred to as Sistrunk's operation. Malignancy is rarely encountered in TDCs; when such rare tumors do develop (in the order of 1% or so of patients with TDCs), they usually take the form of either papillary carcinoma of thyroid origin, or squamous carcinoma.

Traitement endoscopique au laser des fistules de la 4e poche endobranchiale

OBJECTIVES

To describe a new method of treatment of the fourth branchial pouch sinuses by laser endoscopic coagulation of the fistula.

MATERIAL AND METHODS

Retrospective study of two children aged 3 and 12 years with fourth branchial pouch sinuses. Both children presented recurrent cervical abscesses. The diagnosis was established on results of ultrasound, barium study, CT scan and pharyngoscopy. After recovering from infection, the definitive treatment was a laser diode cauterization of the fistulous route and its pharyngeal opening.

RESULTS

Outcome was rapidly favorable in both children without complications or recurrence.

DISCUSSION

These two cases and other reports in the literature confirm the role of endoscopic management for the treatment of the fourth branchial pouch sinus. Laser treatment is especially useful because of its convenience, its harmlessness and its reliability.

CONCLUSION

Fourth branchial pouch sinuses are rare. Surgery, which can be difficult and not without risks, is the generally accepted treatment. This new laser method combines ease of treatment and efficacy.

Cervicomediastinal Thymic Cyst: Report of a Case

Congenital thymic cysts are rare. Consequently, they are often misdiagnosed and not included in the preoperative differential diagnosis of neck masses. We report the case of a 7-year-old boy with a large cervicomediastinal thymic cyst to increase the awareness of this unusual entity. We discuss the clinical features, presentation, and pathogenesis of thymic cysts.

Congenital sublingual teratoid cyst: a case report and literature review

Head and neck dermoid cysts comprise less than 10% of all dermoid cysts. The sublingual location is very rare. One hypothesis for their etiology is that they arise from entrapment of epithelial debris or rests during the midline fusion of the first 2 branchial arches. They are classified as epidermoid, dermoid, and teratoid cysts. Sublingual cysts are slow-growing lesions generally seen in the second and third decades of life. They are rare in childhood. The cysts may interfere with swallowing and breathing. Rarely, they may show malignant transformation. Surgical extirpation is the treatment of choice.

Pediatric soft tissue lesions

Soft tissue oral and perioral lesions in the pediatric population are numerous and occur in various clinical presentations. Some conditions observed in children share characteristics with adult-onset disease. Other oral lesions are limited to the pediatric population. This article focuses on the more common soft tissue manifestations in children. Rather than a comprehensive review of pediatric oral pathology, the article offers an overview of selected clinical conditions often encountered in young patients.

Unusual association of congenital middle ear cholesteatoma and first branchial cleft anomaly: management and embryological concepts

OBJECTIVE

To report two cases of an undescribed association of first branchial cleft fistula and middle ear congenital cholesteatoma and to discuss management and embryological hypothesis.

DESIGN

Retrospective study and review of the literature

RESULTS

Both patients were young girls free of past medical or surgical history. Surgical removal of the first cleft anomaly found in the two cases a fistula routing underneath the facial nerve. Both cholesteatomas were located in the hypotympanum, mesotympanum. In one case, an anatomical link between the two malformations was clearly identified with CT scan.

DISCUSSION

The main embryological theories and classification are reviewed. A connection between Aimi's and Michaels' theories (congenital cholesteatoma) and Work classification might explain the reported clinical association.

Thymic cyst in the neck

A rare case of a thymic cyst in the neck containing both thymus and parathyroid tissue in a 7-year-old boy is presented. The clinical presentation, diagnostic evaluation, surgical management and histopathological features are described. The embryology of cervical thymic cysts and the differential diagnosis of cystic neck masses in children are briefly reviewed. The diagnosis is seldom made preoperatively. Surgical resection is the treatment of choice for definitive diagnosis, resolution of symptoms and cure.

Thyroglossal duct carcinoma in children: case presentation and review of the literature

Carcinoma within the thyroglossal duct (TGDCa) is a very rare pediatric tumor. This report presents the case of a 15-year-old girl with TGDCa, reviews the previously published pediatric cases of this tumor, and provides diagnostic and therapeutic considerations in TGDCa in children. Twenty one cases of TGDCa have been reported, 12 of them in females. Mean age at presentation was approximately 13 years for females and approximately 12 years for males. The duration of a midcervical mass prior to the diagnosis of TGDCa varied from 3 weeks to 8 years. The size of the neck mass at presentation averaged 2 cm-4 cm. All masses were asymptomatic, and the diagnosis of TGDCa was incidental following surgery. All pediatric cases of TGDCa reported thus far were of the papillary type, except for 3 patients who presented with a mixed papillary-follicular carcinoma. Capsular invasion was detected in 10 (45%) patients. Local invasive disease was found in 5 (23%) patients, but all removed thyroid glands (12) were free of carcinoma. One patient had lung metastases. Thyroidectomy with subsequent radioiodine ablation was the treatment of choice in the majority of the cases. The reported prognosis for TGDCa in children was favorable, with only one reported death.

Congenital midline cervical cleft of the neck: a series of five cases

Congenital midline cervical cleft is a very uncommon malformation. Through a series of five cases treated in the pediatric otolaryngology head and neck surgery department of an academic care center, authors discuss embryopathogeny and therapeutic management. It appears that complete surgical removal leads to cure in classic cases. No recurrence was noted and cosmetic damages were minor.

An unusual presentation of neck dermoid cyst

Congenital masses are the most common non-inflammatory neck lesions in children. Although usually present at birth, they can appear at any age. Dermoid cysts are benign lesions of congenital origin usually presenting as a midline neck mass. They rarely appear in the lateral region of the neck. Lateral cervical dermoid cyst is presented as a rare, unusual case, and differential diagnosis and management are discussed in light of recent literature.

Thyroglossal duct cysts: presentation and management in children versus adults

OBJECTIVES

To determine if the clinical presentation of thyroglossal duct cysts (TGDC) varies between children and adults and whether this knowledge helps optimize the surgical management.

METHODS

We retrospectively identified all patients with TGDC managed in our department between 1992 and 2002. We reviewed the patients' charts and recorded their gender, age at diagnosis, clinical presentation, radiologic imaging, surgical management, post-operative complications, and recurrence rate and compared the variables between the children and adults.

RESULTS

Twenty-one children and 41 adults were treated for TGDC. Of the children, 57% were male and 43% were female, whereas 49% of the adults were male and 51% were female (P = 0.53). The average age was 6 +/- 5 years in children and 45 +/- 16 years in adults, which demonstrates a bimodal distribution. Forty-three percent of children and 42% of adults presented with an infected neck mass (P > 0.99). Among our patients, 96% of the adults and 100% of the children underwent a Sistrunk operation. Four children developed a wound infection that resolved with antibiotics. One adult developed a haematoma and another developed a wound seroma. There was one recurrence among adults and one among children, both of whom were treated with a second Sistrunk procedure.

CONCLUSIONS

There appears to be a bimodal distribution for age at presentation of TGDC. Since the differential diagnosis among adults is broader, the opportunity for misdiagnosis is greater. However, once the correct diagnosis is made, the surgical management and post-operative outcome between adults and children is the same.

Fourth branchial complex anomalies: a case series

OBJECTIVE

Anomalies of the fourth branchial arch complex are exceedingly rare, with approximately forty cases reported in the literature since 1972. The authors report experience with six fourth arch anomalies.

METHODS

Retrospective chart review of six consecutive patients presenting to the pediatric otolaryngology service at a tertiary care center with anomalies referable to the fourth branchial arch.

RESULTS

All six patients presented within the first or second decade of life. All six had left-sided disease. Four patients presented with recurrent neck infection, one with asymptomatic cervical masses, and one with a neck mass and respiratory compromise. One patient had prior surgery presented with a recurrence. Diagnosis of fourth arch anomalies was suggested or confirmed by computed tomography and flexible laryngoscopy. Treatment was surgical in five patients; one patient is awaiting surgery. Surgical procedures included resection of the mass and endoscopic cauterization of the inner opening of the cyst.

CONCLUSIONS

The presentation of a cervical mass, especially with recurrent infections and especially on the left side, in a child in the first or second decade of life heightens suspicion for an anomaly of the fourth branchial arch. Diagnosis can be difficult, but is aided by the use of flexible laryngoscopy, Computed tomography (CT) scanning and ultrasonography. Surgical resection of the cyst and cauterization of its pyriform sinus opening should be undertaken to minimize recurrence.

Rapidly growing sublingual dermoid cyst throughout pregnancy

Dermoid cysts (DCs) are subcutaneously located cystic masses that contain epithelium and adnexal structures. They are most commonly located in the ovaries and sacral region. Seven percent of DCs are found in the head and neck. Sublingual DCs may develop above the mylohyoid, presenting in the floor of the mouth or below it, causing a submental or submaxillary mass. We presented a case with a sublingual giant DC enlarged rapidly during pregnancy manifesting deglutition and mild respiratory problems. The growth of a DC of the neck may be accelerated in pregnancy period and may ensue severe symptoms challenging both mother and fetus. We proposed the removal of sublingual DCs before attempting to conceive to eliminate the risk of rapid growth of DC that results in respiratory and deglutition problems.