First branchial cleft anomalies involving the tympanic membrane and middle ear

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System

PURPOSE

Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs.

METHODS

Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study.

RESULTS

The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05).

CONCLUSION

The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

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.

First branchial cleft fistula presenting with internal opening on the Eustachian tube: Illustrated cases and literature review

OBJECTIVE

Two cases of first branchial cleft fistula with internal opening on the Eustachian tube are reported and the diagnosis, management and embryological hypothesis are discussed.

DESIGN

Retrospective study and review of the literature.

RESULTS

Both patients were young boys with first branchial cleft anomaly clearly identified by computed tomography fistulography scan and direct Methylene Blue dye injection. In both cases, surgical removal revealed a fistula with internal opening located on the Eustachian tube near the nasopharynx.

DISCUSSION

The main embryological theories and classification are reviewed. A connection between the theories of first branchial apparatus development and the classification by Work might explain the reported clinical association.

First branchial cleft anomaly: clinical insight into its relevance in otolaryngology with pediatric considerations

First branchial cleft anomalies (FBCA) represent a small subset of congenital malformations in neck. Prime objective of this study is to share our experience with FBCA, emphasize its relevance in otolaryngology and deal with its pediatric perspective. Embryology, pathologic anatomy and varied spectra of clinical presentations of FBCA are discussed. Along with this we have illustrated three different cases; all of them were of pediatric age group and were misdiagnosed by their treating specialists elsewhere. In this article we have also laid special emphasis on its pediatric considerations. FBCA are mostly misdiagnosed due to their unfamiliar clinical signs and symptoms. Swellings may masquerade as other neck masses. Majority of patients give a history of previous incision and drainage. While dealing with pediatric patients the important factors to be kept in mind are the age of child, superficial course of facial nerve, any associated agenesis of parotid gland. Alteration in surgical technique may be required in children. A thorough medical examination with high index of clinical suspicion should be kept in mind while dealing with such anomalies. Owing to their complex presentation and close relation with facial nerve they are challenging lesions for surgeons.

A misdiagnosis: duplication of the external auditory canal

We present imaging and clinical findings of a case with a duplicated external auditory canal, which led to misdiagnosis secondary to lipomatous content on imaging studies prior to surgery. It is a very rare congenital anomaly. This entity is usually misdiagnosed not only clinically but also radiologically. This leads to a delay and failure in diagnosis and treatment. To the best of our knowledge, herein is the first case report of the duplication of the external auditory canal presenting with dominant lipomatous imaging features. In this report, we aim to draw attention to the atypical presentation.

Unusual extension of the first branchial cleft anomaly

First branchial cleft is the only branchial structure that persists as the external ear canal, while all other clefts are resorbed. Incomplete obliteration and the degree of closure cause the varied types of first branchial cleft anomalies. They were classified based on the anatomical and histological features. We present an unusual type of first branchial cleft anomaly involving the external auditory canal, the middle ear and the nasopharynx through the eustachian tube.

Congenital postauricular swelling in a child

First branchial cleft cysts develop as a result of incomplete fusion of the cleft between the first and second branchial arches. In 1972, Work introduced a modified classification of these anomalies that recognized the existence of two types. Type I lesions, which are extremely rare, present as a cystic mass posterior to the pinna and concha. Type II lesions represent a duplication of both the membranous and cartilaginous portions of the external ear canal. They are associated with fistulas in the concha or in the external ear canal. Clinical and surgical management is often difficult because these anomalies have a variable relationship to the facial nerves. We describe a rare localization of a type I first branchial cleft cyst in a child and the clinical management with successive surgical treatment.

Lateral cervical cleft: a previously unreported anomaly resulting from incomplete disappearance of the second pharyngeal (branchial) cleft

The authors present a 2-year-old boy with a skin defect located in the right lateral side of the neck. They suggest the defect is a partial failure of disappearance of the second pharyngeal (branchial) cleft and propose a name of lateral cervical cleft.

An unusual cavity within the styloid process

A rare case of an unusual sinus within the styloid process is described. The radiological appearance of this malformation is presented with CT-scans and a hypothesis for its development is presented. The malformation is designated as "Recessus processus styloidei" and this entity is considered to be a dysgenesis of the second branchial arch.

[Mode of presentation of fistula of the first branchial cleft]

BACKGROUND

The rarity and diverse presentations of first branchial cleft anomalies lead to misdiagnosis and inadequate treatment.

POPULATION AND METHODS

We report 21 cases of such anomalies in children aged 7 months to 8 years whose diagnosis was presumed on clinical presentation and confirmed at surgery.

RESULTS

The symptoms were intractable otorrhea, periauricular, cervical and parotid suppuration, which were present in two, 12, five and three cases, respectively. Two children had an abnormal eardrum and three an epidermic cyst in the external ear canal.

CONCLUSION

The diagnosis of a first branchial cleft anomaly must be considered in any patient with a history of recurrent periauricular swelling, a sinus located high in the neck, or a mass in the external auditory canal.

Periauricular cysts and sinuses

Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.

Unusual presentation of a first branchial cleft

An atypical case of a first branchial cleft presenting with a cutaneous fistula and an epidermoid cyst of the external auditory canal is reported. The relevant embryology of the branchial apparatus is summarized, and variations of first branchial anomalies are discussed. The relationship with a congenital cholesteatoma is discussed.