The congenital sternoclavicular sinus in children: Our experience of 56 cases

OBJECTIVES

The objective of this study is to explore the clinical diagnosis and treatment of the congenital sternoclavicular sinus in the region of sternoclavicular joint, providing valuable insights for clinical practice in children.

METHODOLOGY

A retrospective review of case notes was conducted for all patients treated for congenital sternoclavicular sinus at a tertiary care pediatric otolaryngology practice from January 2022 to September 2023.This review analyzed the clinical presentations, imaging examination, pathological examination, and treatment.

RESULTS

A total of 56 patients with congenital sternoclavicular sinus were included in the study, with a mean age of 4.10 ± 2.57 years old. Among these patients, the sinuses were located on the left side in 43 cases,on the right side in 12 cases,and bilaterally in one case.While two patients never experienced inflammation, 54 patients did, and 45 of them underwent incision and drainage before excision. Imaging examination, including ultrasonography and computerized tomography (CT) scans, revealed characteristics such as thickening of subcutaneous tissue,subcutaneous tubular structures or tubercles in front of the clavicle,and irregularly shaped lesions with clear borders and uneven internal low echo, Pathological examination confirmed that the sinuses were lined by squamous epithelium in all patients.

CONCLUSIONS

The congenital sternoclavicular sinus may be a remnant of the fourth branchial cleft on the skin side.Complete resection of the sinus during the quiescent phase of inflammation is the recommended curative treatment to prevent recurrent infection.

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.

Age-related outcomes after pediatric branchial cleft cyst excision via NSQIP-P

OBJECTIVE

Branchial cleft cysts present at varying ages; sometimes excision is delayed because of concern about operating in small children. Our goal was to determine if outcomes and complications differed among pediatric age groups.

STUDY DESIGN

Retrospective, cross-sectional.

SETTING

American College of Surgeons' National Surgical Quality Improvement Pediatric database.

METHODS

Patients who underwent a branchial cleft cyst excision between 2016 and 2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database. Patients with CPT code 42,815: 'excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx' as their primary procedure were included. Variables of interest included patient demographics, comorbidities, pre-operative risk factors and complications.

RESULTS

2267 patients with median age of 3.9 (IQR: 7.4, range: 0.04-17.9) years were included. The most common pre-operative risk factors were 149 (7 %) patients with prematurity, 136 (6 %) with developmental delay, 135 (6 %) with congenital malformation, and 128 (6 %) with open wound or wound infection. 68 (3 %) patients experienced at least one post-operative complication, with 73 post-operative complications documented in total. Surgical site infections were the most common complications with 49 (67.1 %) superficial infections, 11 (15.1 %) deep infections, and 4 (5.5 %) organ/space infections. Surgical site infections were the most common reason for related readmission. Duration of anesthesia and operative time increased significantly as patient age increased (p < .001 for both). There was no significant correlation between age and complication incidence.

CONCLUSION

Branchial cleft cyst excision is a relatively safe operation with a low complication rate, even in young pediatric populations.

Ultrasound diagnosis and treatment of branchial cleft cyst and preoperative management

OBJECTIVE

The ultrasonic diagnosis of cervical and facial cystic masses, as well as cases of missed diagnosis and misdiagnosis, was examined, to improve the diagnosis of branchial cleft anomalies.

METHODS

A retrospective analysis was conducted on 17 patients with branchial cleft cyst anomalies, including 11 males and 6 females, aged 12-53 years, with an average age of 33 ± 2 years, were unilateral single. All patients who underwent an ultrasound examination and image storage for retrospective analysis, and both longitudinal and transverse sections were scanned to observe the shape, size, boundary, peripheral relationship, and blood flow signal of the masses. All cases were examined with an enhanced CT scan, and pathological reports were generated.

RESULTS

Among the 17 cases of branchial cleft anomalies, 15 cases were branchial cleft cysts, while one case involved fistula formation and one case involved sinus tract formation. Based on the type of branchial cleft, the first, second, and third cysts were classified in 4, 12, and 1 case, respectively. The sensitivity rate and specificity of ultrasonic diagnosis were 14/17 (82.4%) and 4/6 (66.7%), respectively. Ultrasonic characteristic analysis for the masses can be found in simple cystic masses or hypoechoic masses, most of them are of a regular shape and have a distinct boundary, and almost no blood flow signal. All patients who were misdiagnosed exhibited blood flow signals, including 1 patient with an abundant blood flow signal, 1 patient suspected of having ectopic thyroid with an abnormal function due to the rat-tail sign, 2 patients misdiagnosed as local inflammatory focus, and 1 patient misdiagnosed with tuberculous lymphadenitis.

CONCLUSION

Ultrasound has a detection rate of up to 100% for cervical and facial masses, providing a fundamental determination of lesion characteristics and specific guidance for preoperative diagnosis. If the blood flow signals can be identified and carefully considered their peripheral relationship, the diagnostic rate can be improved.

Reworking Classification of First Branchial Cleft Anomalies

OBJECTIVES

To evaluate the clinical features of first branchial cleft anomalies (BCAs) and their relationship to pre-operative imaging, pathologic data, and post-operative surveillance outcomes. Additional aims were to assess the validity of the Work classification and describe features of recurrent cysts.

METHODS

Records for 56 children (34 females, 22 males; age at surgery of 5.6 ± 4.4 years) collected over a 12-year period (2009-2021) were reviewed. Imaging and pathologic slides were re-reviewed in a blinded fashion by experts in those respective areas. Parents were contacted via telephone to obtain extended follow-up. An alternate classification method based on the presence (type II) or absence (type I) of parotid involvement is provided.

RESULTS

Only 55% of first BCAs could be successfully classified using Work's method. First BCAs within the parotid were more likely to present with recurrent infections, involve scarred tissue planes and lymphadenopathy, and demonstrate enlarged lymphoid follicles on pathology. The overall recurrence rate was 16%, and recurrence was 5.3 times more likely when external auditory canal cartilage was not resected. Preoperative imaging was useful for predicting the extent of surgery required and the presence of scarred tissue planes.

CONCLUSION

First BCAs within the parotid gland involve more difficult and extensive surgical resection and the potential for morbidity related to facial nerve dissection. Appropriately aggressive surgical resection, which may include the resection of involved ear cartilage, is necessary to prevent morbidity related to recurrence.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:459-465, 2024.

New classification and surgical strategy for work type I congenital first branchial cleft anomalies in children

PURPOSE

To investigate the anatomical relationships between the structures adjacent to the cartilaginous portion of the ear canal in children with Work type I congenital branchial cleft anomalies (CFBCAs) and to develop new classifications and surgical strategies.

METHODS

Retrospective analysis was performed on 50 children with Work type I CFBCAs admitted between December 2018 and December 2022.

RESULTS

Among the 50 children, total parotidectomy was performed on 49 sides. In 44 cases (88%), the main body of the lesion was closely associated with the cartilage of the inferior ear canal wall. Among these cases, the lesions in 40 cases occurred within the space enclosed by the dorsal inferior wall cartilage, mastoid process, and parotid gland, while in the remaining four cases, the lesions were located between the anterior inferior wall cartilage and parotid gland. Based on the preoperative imaging observations, clinical manifestations, and intraoperative findings, the cases were classified into 6 subtypes (a to f) including 21 cases (42%) of Type Ia (inferior wall of EAC), 7 cases (14%) of Type Ib (bottom wall of EAC), 12 cases (24%) of Type Ic (posterior-inferior wall of EAC), 4 cases (8%) of Type Id (anterior-inferior wall of EAC), 4 cases (8%) of Type Ie (anterior ear wall of EAC), and 2 cases (4%) of Type If (isolated from parotid).

CONCLUSION

Surgical intervention is the only treatment for first branchial cleft anomalies and a comprehensive understanding of the classifications will help with the precise localisation and excision of the lesions.

Collaural fistula: Our experience

Branchial cleft anomalies are congenital, arising from the first to the fourth pharyngeal clefts. The most common is a second arch anomaly. As it is congenital, it presents at birth though may become symptomatic later. The spectrum of anomalies includes sinus, cyst, or fistula formation or a combination of these. Here we present a case series based on first cleft anomalies. The principles of management include early diagnosis, excision of any fistulous tract, and prevention of injury to the facial nerve.

Pharyngeal Arches, Chapter 1: Normal Development and Derivatives

The pharyngeal arches form the cornerstone of the complex anatomy of the face and neck. These embryologic structures are the foundation of face and neck development, and anomalous growth can result in craniofacial abnormalities. Surgeons who manage head and neck pathology and pathoanatomy will invariably encounter conditions associated with aberrant pharyngeal arch anatomy, and a thorough understanding of the normal and pathological development of these important structures is paramount to accurate diagnosis and treatment. This manuscript is the first of a three-part educational series that addressed the pharyngeal/branchial arch embryology, development, nomenclature, and normal anatomy (Part I), pathologic anomalies of ear and neck derived from abnormal development of the arches (Part II), and different types of orofacial clefts, including Tessier clefts (Part III).

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.

First Branchial Cleft Anomalies: Rare Work Type I and Type II Entities

First branchial cleft anomalies (FBCAs) are the most infrequent malformations that occur during the development of the branchial apparatus, appearing in less than 8% of all branchial anomalies. Traditionally, they are classified into Work type I and II, depending on their origin. We present a pair of rare FBCAs: a case of a preauricular Work type I cyst with twin fistulae coursing toward the parotid gland and a Work type II cyst of significant dimensions.

[A case report of the first and second branchial arch syndrome with torticollis]

A 54-month-old female patient presented to the department of ophthalmology with abnormal head posture and facial asymmetry for two years. The patient's facial development was asymmetrical, with the middle 1/3 of the left side shorter than the right side. The left ear is less malformed than the right. There was no obvious abnormality in corneal light reflex and eye movement. Head tilt test ( -). So, paralysis of the superior oblique muscle was excluded. In consultation with the department of maxillofacial surgery, the patient was confirmed as the first and second branchial arch syndrome and torticollis.

[Study on CT features of congenital branchial cleft anomaly in children]

Objective:To summarize the CT features of congenital branchial cleft anomaly in children, to reduce misdiagnosis and improve surgical strategy. Methods:This study enrolled 323 pediatric patients with congenital first branchial cleft anomaly, congenital second branchial cleft anomaly and congenital piriform sinus fistula confirmed by surgery and post-operative histopathology, who was admitted to Shanghai Children's hospital from August 2014 to January 2021., CT imaging data were retrospectively analyzed. Results:A total of 323 children with congenital branchial cleft deformity were included. There were 145 males and 178 females, aged from 22 days to 15 years. 119（119/323, 36.8%） cases were diagnosed as congenital first branchial cleft anomaly. Among them, 96 cases（96/119, 80.67%） were related to the wall of external auditory canal, and 89 cases（89/119, 74.78%） were related to parotid gland. The positive rate of CT examination was 87.4%（104/119）. 57 cases（57 / 323, 17.6%） had congenital second branchial cleft anomaly. Among them, 46 cases（46/57, 80.7%） were related to submandibular gland. The positive rate of CT examination was 84.2%（48/57）. 147 cases（147/323, 45.5%） had congenital piriform sinus fistula, in which 129 cases（129/147, 87.8%） were related to thyroid. The positive rate of CT was 89.1%（131/147）. Conclusion:The CT findings of congenital first branchial cleft anomaly are characterized by lesions in the inferior and/or posterior wall of ipsilateral external auditory canal and parotid gland. The CT features of congenital second branchial cleft anomaly are that the lesion is located on the ipsilateral submandibular gland （posterior and medial）. The CT features of congenital piriform sinus fistula are that the focus is located on the dorsal side of the upper pole of the lateral lobe of the thyroid gland.

[The role of triangular space of ear canal-parotid-mastoid in the surgery for first branchial cleft anomalies]

Objective:To explore the role of triangular space of ear canal-parotid-mastoid in the operation of the first branchial cleft deformity. Methods:The clinical features and intraoperative characteristics of 25 cases with first branchial cleft anomalies who underwent surgery from September 2011 to September 2019 were analyzed, and the role of the triangular space of ear canal-parotid-mastoid in the surgery was explored. Results:Following dissecting and lesions removel of the triangular space of ear canal-parotid-mastoid, all the lesions were resected completely. Eighteen cases had fistula in the floor wall of ear canal, seven cases had duplicated of external auditory canal in the inferior of the floor wall. The recurrent cases were all attributable to the residual lesions in the triangular space. There was no recurrence, salivary leakage or stenosis of external canal. One case suffered from HB2 level facial paralysis. Conclusion:Surgery is the optimal treatment for first branchial cleft anomalies. Following the active dissection of the ear canal-parotid gland-mastoid space and depending on the microscopic operation, the deep lesions would be exposed clearly and the facial nerve could be marked and protected. Cleaning this triangle space can lead to completely lesion removal, avoid facial paralysis, salivation and recurrence.

Bilateral second pharyngeal cleft cysts in 2 calves on the same farm

Pharyngeal cleft cysts (also called branchial cleft cysts) are rare congenital defects of the pharynx region that appear as soft, fluctuant cystic structures on the ventral neck. These cysts are formed by anomalous regression of the pharyngeal clefts during embryonic development and are lined by pseudostratified columnar to squamous, partially ciliated epithelium on histopathology. Development of these cysts is sporadic, with no currently identified risk factors in veterinary species. The cysts are typically unilateral, and primarily diagnosed in mature animals of various species. The objective of this article is to report 2 cases of bilateral second pharyngeal cleft cysts in 2 calves with no shared pedigree, located on the same farm. To the authors' knowledge, this is the first report of geographically linked second pharyngeal cleft cysts in veterinary species, and the first cases of bilateral cysts in cattle. Key clinical message: Pharyngeal cleft cysts are an important differential for soft, fluctuant, and cystic structures on the ventral neck of all species. These cases are typically unilateral, diagnosed in mature animals and are sporadic with no currently identified risk factors in veterinary species.

An unexpected cyst of the ear lobule

Branchial cleft anomalies (BCA) are among the most common congenital anomalies found in the pediatric head and neck. The embryology of these congenital anomalies is well understood, which allows clinicians to anticipate their diagnosis when a pediatric patient presents with a head or neck mass. The predictable anatomy of the various types of BCA allows for improved surgical planning to prevent recurrence and ensure complete resection. This report details an unusual location of a first BCA located in the ear lobule of a 10-month old male. There has been no documented first BCA at the ear lobule in the literature.

Presentation of a branchial cleft anomaly in an adult

ABSTRACT

Branchial cleft anomalies are the second most common type of congenital neck mass and typically are diagnosed in patients under age 5 years. This article describes a rare presentation of an adult with a branchial cleft anomaly.

Feasibility of same day surgery for pediatric second branchial cleft anomalies

OBJECTIVE

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation.

METHODS

A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.

RESULTS

There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay.

CONCLUSION

Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

Bilateral cervical chondrocutaneous branchial remnants: A case report and a review of the literature

RATIONALE

Cervical chondrocutaneous branchial remnants are rare, benign, congenital anomalies, frequently seen bilaterally.

PATIENT CONCERNS

Here, we report the case of a 4-month-old female infant who presented with bilateral lower neck skin tag since birth.

DIAGNOSIS AND INTERVENTIONS

The patient underwent mass excision. The final pathological diagnosis was bilateral cervical chondrocutaneous branchial remnants with hyaline cartilage.

OUTCOMES

No complications were observed after excision. One-year follow-up revealed no recurrence.

LESSONS

Bilateral chondrocutaneous branchial remnants are rare anomalies. They are often associated with cardiac or genitourinary abnormalities. Therefore, additional preoperative imaging of the abdomen and heart are recommended.

[A 4-year-old girl with a recurrent infection in the neck: a familiar picture with a rare cause]

BACKGROUND

Infections of the neck are frequently seen in young children and are usually harmless and transient. In the case of atypical symptoms, however, it is important to be alert to the possibility of less common causes requiring specific treatment.

CASE DESCRIPTION

A 4-year-old girl was seen in the outpatient clinic with a recurrent, inflamed swelling in the neck. The swelling persisted despite repeated incision and drainage. Further investigation with MRI revealed a primary branchial cleft fistula, Work type 2. The epithelialized cartilaginous fistula tract ran from the external auditory canal to the neck, very close to the facial nerve, but could be surgically removed without damage to the nerve.

CONCLUSION

In a child with a recurrent swelling or abscess in the neck, with or without a fistula, an extensive differential diagnosis is required including branchial cleft fistula.

The utilization of selective neck dissection in the treatment of recurrent branchial cleft anomalies

To investigate the characteristics of recurrent branchial cleft anomalies (BCAs) and to evaluate the surgical technique and outcomes of patients undergoing reoperation.From January 2005 to August 2018, the clinical data of 216 patients with recurrent second, third, and fourth BCAs were retrospectively analyzed. According to the embryological and anatomical features of the cleft palate and recurrence site, selective neck dissection techniques were used for surgical treatment.Among all 216 patients, 203 healed by primary healing. Twelve patients with local infections and 1 patient with a pharyngeal fistula healed after dressing changes. Eleven patients experienced transient hoarseness and recovered after a few months. Three patients developed permanent hoarseness, and 5 patients developed coughing after eating and drinking. Three patients underwent internal jugular vein ligation. Only 4 recurrences occurred during a follow-up period of more than 1 year. The total cure rate was 98.15%.Selective neck dissection is an effective and safe surgical treatment for recurrent second, third, and fourth branchial cleft anomalies.

Fourth branchial anomalies: Predictive factors of therapeutic success

PURPOSE

The purpose of this work was to determine the epidemiology and the predictive factors of success of the surgical management of fourth branchial anomalies.

METHODS

This is a multicentric retrospective review from 1998 to 2016 of patients who presented with an endoscopically-confirmed fourth branchial pouch anomaly. Data were analyzed according to sex, age, clinical features, number of recurrences, treatment modalities (endoscopic and/or cervicotomy), post-operative complications and follow-up.

RESULTS

Fifty-two children have been included. The average age at diagnosis was 4.5 years. Among them, 73.1% were female, 11.4% were neonatal forms; 94.2% of lesions were left-sided; 75% of patients presented a cervical abscess as first symptom, and 7.7% of children presented with dyspnea. Average time between first symptoms and management was 9.5 months. Management was endoscopic in 73.1% of patients (laser in 84.2%, coagulation in 15.8%) with about a third of recurrence after one procedure. Overall success of endoscopic procedures reached 84.2%. A cervical open surgery was performed in 26.9% as first line treatment. Overall success of cervicotomy reached 85.7%. No complications of endoscopic surgery have been identified. There were 35.7% complications of cervicotomy (2 recurrent nerve palsy, 2 keloid scars, 1 pharyngostoma). An association was proved between recurrences and initial abscess (OR = 2.44), and with age between 3 and 5 (OR = 4).

CONCLUSION

Endoscopic treatments appear to be effective in first line approach in the management of fourth branchial anomalies, offering an excellent efficiency with rare complications. We identified two risk factors of recurrence: age between 3 and 5 years old and history of cervical abscesses.

LEVEL OF EVIDENCE

IV.

Differences in management outcome for first branchial cleft anomalies: A comparison of infants and toddlers to older children

OBJECTIVE

First branchial cleft anomalies (FBCAs) are rare and often misdiagnosed, which can delay proper management and increase surgical risks. Complete excision often requires parotidectomy with facial nerve dissection. The literature reports that younger patients more often have lesions deep to the nerve with higher rates of nerve injury. We hypothesized that the rate of nerve injury and complications in children with FBCAs was not different in those ≤2 years of age compared to those >2 years of age.

METHODS

Retrospective review of pediatric patients who underwent resection of histopathologically confirmed FBCAs between 2007 and 2017 at a tertiary care, pediatric hospital. Presenting symptoms, lesion classification, prior procedures, imaging techniques, extent of surgery performed, facial nerve position, and complications were reviewed and compared between patients ≤2 years of age and >2 years of age at time of surgery.

RESULTS

43 cases of FBCAs were included in the study: 12 in the younger group and 31 in the older group. There was no difference between groups regarding the presenting symptoms, gender breakdown, lesion classification, prior procedures performed, or extent of surgery. Lesions were more commonly deep to or running between branches of the facial nerve in the younger group (33.3% vs 9.7%, p = .0496). Rates of postoperative complications and facial nerve weakness were comparable between the younger and older groups (8.3% vs 25.8%, p = .206; 25.0% vs 16.1%, p = .503). In combining the age groups, FBCAs located deep to the facial nerve had increased risk of nerve weakness postoperatively (RR 7.2) and those with a history of prior incision and drainage or resection had increased risk of postoperative complications (RR 2.36). Imaging was obtained on all subjects with accuracy rates of 80-100%.

CONCLUSION

Presenting characteristics of FBCAs in patients ≤2 years of age and >2 years of age are comparable, but lesions in younger subjects had a greater likelihood of being deep to or coursing between branches of the facial nerve. However, the rates of facial nerve injury and postoperative complications are comparable in younger and older children, owing likely to accurate preoperative imaging and appropriate surgical planning.

Further evidence for complex inheritance of holoprosencephaly: Lessons learned from pre- and postnatal diagnostic testing in Germany

Holoprosencephaly (HPE) has been defined as a distinct clinical entity with characteristic facial gestalt, which may-or may not-be associated with the true brain malformation observed postmortem in autopsy or in pre- or postnatal imaging. Affected families mainly show autosomal dominant inheritance with markedly reduced penetrance and extremely broad clinical variability even between mutation carriers within the same families. We here present advances in prenatal imaging over the last years, increasing the proportion of individuals with HPE identified prenatally including milder HPE forms and more frequently allowing to detect more severe forms already in early gestation. We report the results of diagnostic genetic testing of 344 unrelated patients for HPE at our lab in Germany since the year 2000, which currently with the application of next generation sequencing (NGS) panel sequencing identifies causal mutations for about 31% (12/38) of unrelated individuals with normal chromosomes when compared to about 15% (46/306) using conventional Sanger sequencing and Multiplex Ligation-dependent Probe Amplification (MLPA). More comprehensive genetic testing by our in house NGS panel sequencing of 10 HPE associated genes (MiSeq™ and NextSeq™500, Illumina, Inc., San Diego, CA) not only allowed to include genes with smaller contribution to the phenotype, but may also unravel additional low frequency or more common genetic variants potentially contributing to the observed large intrafamiliar variability and may ultimately guide our understanding of the individual clinical manifestation of this complex developmental disorder.

Distribution, Management Difficulty and Outcome of Branchial Anomalies

Branchial arch anomalies are one of the most common congenital anomalies of the neck. Developmental anomalies of the branchial apparatus account for 17% of all pediatric cervical masses. This study aimed to focus on proper diagnosis of branchial anomaly and describe occurrence, presentation, management and outcome of usual and unusual types. This ten-year prospective observational study was conducted from November 2005 to November 2015 including 2-year postoperative follow-up of the patients in Department of ENT, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Total 89 patients were enrolled for this study. Information was recorded on Clinical examination, relevant investigation, Per-operative findings and Histo-pathological findings. After receiving Histo-pathological findings 61 cases were proved as branchial arch anomalies. Ultrasonography and Histopathology was done for every patient. Fistulogram and sinogram was done for patient of fistula and sinus respectively. CT scan was needed for 9 patients, MRI for 3 patients and 12 patient undergone FNAC. Outcomes of those patients were described in terms of Hospital stay, Complications and Follow up studies. Data analysis was done by Standard Statistical Method.Presentation of a number of participant's mimics Branchial arch anomalies; 4.91% was syndromal. Second branchial arch anomalies were the highest. Management was exclusively surgical. Recurrence rate was about 6.56%. Surgery is the tool for diagnosis, treatment, preventing complications, avoiding carcinoma for branchial arch anomalies.

Bilateral Pharyngoceles (Branchial Cleft Anomalies?) and Endoscopic Surgical Considerations

A case report of bilateral pharyngoceles without a history of elevated intrapharyngeal pressures is used to support the hypothesis that pharyngoceles may be an adult manifestation of an internal branchial sinus anomaly. The development of a pharyngocele from a branchial sinus origin would suggest a predictable relationship to the hypoglossal, glossopharyngeal, and superior laryngeal nerves, which may influence the choice of surgical approach (open versus endoscopic) and the counseling of patients who are considering surgical correction.

Branchial cleft and pouch anomalies in childhood: a report of 50 surgical cases

BACKGROUND AND AIMS

Branchial abnormalities occur when there is disturbance in the maturation of the branchial apparatus during fetal development. Branchial anomalies are congenital lesions usually present in childhood, even if they can be diagnosed later for enlargement or infection. A correct diagnosis will lead to proper management: complete surgical excision is the treatment of choice. The purpose of this article is to present clinical features, diagnostic methods and surgical treatment of branchial anomalies in childhood, based on a series of 50 patients.

METHODS

We conducted a retrospective analysis of a total of 50 pediatric patients operated from June 2005 to June 2014 for the presence of branchial cleft anomalies.

RESULTS

27 cases (54 %) presented a second branchial cleft fistula and 11 cases (22 %) a second branchial cleft cyst and one case (2 %) presented both cyst and sinus of the second branchial cleft; four cases (8 %) presented first branchial cleft cyst whereas four cases (8 %) a first branchial cleft sinus and two cases (4 %) a first branchial cleft fistula; one case (2 %) presented a piriform sinus fistula (third branchial cleft). None of our patients presented anomalies of the fourth branchial cleft. All patients underwent surgical treatment and lesions have been removed by excision or fistulectomy. No post-surgical complication occurred. The rate of recurrence was 4 %.

CONCLUSIONS

Pre-operative diagnosis supplies important information to the surgeon for a proper therapy: a complete excision of the lesion without inflammatory signs is essential to avoid re-intervention and to achieve a good outcome.

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.

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.

Complete second branchial cleft anomaly presenting as a fistula and a tonsillar cyst: an interesting congenital anomaly

Branchial cleft anomalies make up 30% of all pediatric neck masses, but complete second branchial cleft anomalies are extremely rare. We report an unusual case of a complete second branchial cleft anomaly that presented as a draining neck fistula and a tonsillar cyst in an otherwise healthy 3-month-old girl. At the age of 7 months, the patient had been experiencing feeding difficulties, and there was increasing concern about the risk of persistent infections. At that point, the anomaly was excised in its entirety. Our suspicion that the patient had a complete second branchial cleft anomaly was confirmed by imaging, surgical excision, and histopathologic analysis.

Second branchial cleft anomaly with an ectopic tooth: a case report

Branchial cleft cysts, sinuses, and fistulas are the most common congenital lateral neck lesions in children. They arise as a result of an abnormal development of the branchial arches and their corresponding ectoderm-lined branchial clefts. Of these diverse anomalies, second branchial cleft lesions are the most common, accounting for approximately 95% of all branchial arch pathologies. We describe what is to the best of our knowledge the first reported case of an ectopic tooth in a branchial cleft anomaly. The patient was a young girl who had other congenital abnormalities and syndromic features and who was eventually diagnosed with Townes-Brocks syndrome. We describe the clinical presentation, management, pathologic analysis, and postoperative outcomes of this case, and we present a brief review of Townes-Brocks syndrome.

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.

[Use of Airwayscope with pediatric intlock in a patient with first and second branchial arch syndrome]

First and second branchial arch syndrome is a congenital anomaly of craniofacial dysplasia involving organs derived from the second branchial arch. The main characteristics are microtia and mandibular hypoplasia. A 6-year-old boy was scheduled for adenoidectomy and bilateral myringotomy and tube placement. Slow induction was performed with oxygen, nitrous oxide, and sevoflurane. No difficulties were encountered during mask ventilation, and rocuronium was administered intravenously. His epiglottis was not visible during laryngoscopy. Therefore, we used the Airwayscope (AWS). His glottis was visible after application of cricold pressure from the left side. However, we could not closely conform his epiglottis to the mark on the AWS. Therefore, we passed a fiberoptic bronchoscope through a tracheal tube and placed it in the AWS. We attempted to intubate the trachea, but could not guide the bronchoscope to his glottis. We then attempted to pull the tracheal tube to improve the mobility of the bronchoscope. Control of the bronchoscope consequently became easy We successfully guided it to his glottis and performed tracheal intubation. His condition was stable during the procedure. In conclusion, we safely performed tracheal intubation in a patient with first and second branchial arch syndrome using the AWS and a fiberoptic bronchoscope.

Congenital anomalies presenting as recurrent post-auricular abscesses: an institution based retrospective study

OBJECTIVES

This report is intended to bring out the association of recurrent postauricular abscess in children with various underlying congenital anomalies.

MATERIALS AND METHODS

A retrospective study was done in tertiary care setting from the year August 2005 to February 2012 using the medical record department database to retrieve the patient details. During this study period, a total of 215 children with an age range of 1-14 years were treated at the hospital with postauricular abscess. We analysed the data using appropriate statistical tests for parametric and nonparametric data and setting the p value at 0.05 for significance. For testing the association between the recurrence of abscess and the presence of underlying congenital anomalies, Fischer's t test was used.

RESULTS

A total of 215 patients were studied, of which 41 patients presented with recurrence. 26 of the 41 patients (63.4%) had recurrent postauricular abscess with associated congenital anomalies. Among the 26 patients, in 16 patients (62%), the recurrent abscesses were due to postauricular sinuses. Other less common causes were infected post auricular dermoid cyst, first branchial cysts, collaural fistula and congenital aural atresia. There was a statistically significant association of the recurrence of abscess with presence of underlying congenital anomalies.

CONCLUSION

Paediatric recurrent postauricular abscesses are rare in the post antibiotic era. Their presence should alert a treating physician of an underlying congenital anomaly.

[Management and classification of first branchial cleft anomalies]

OBJECTIVE

We aimed to identify the different courses of first branchial cleft anomalies and to discuss the management and classification of these anomalies.

METHOD

Twenty-four patients with first branchial cleft anomalies were reviewed. The courses of first branchial cleft anomalies and their corresponding managements were analyzed. Each case was classified according to Olsen's criteria and Works criteria.

RESULT

According to Olsen's criteria, 3 types of first branchial cleft anomalies are identified: cysts (n = 4), sinuses (n = 13), and fistulas (n = 7). The internal opening was in the external auditory meatus in 16 cases. Two fistulas were parallel to the external auditory canal and the Eustachian tube, with the internal openings on the Eustachian tube. Fourteen cases had close relations to the parotid gland and dissection of the facial nerve had to be done in the operation. Temporary weakness of the mandibular branch of facial nerve occurred in 2 cases. Salivary fistula of the parotid gland occurred in one patient, which was managed by pressure dressing for two weeks. Canal stenosis occurred in one patient, who underwent canalplasty after three months. The presence of squamous epithelium was reported in all cases, adnexal skin structures in 6 cases, and cartilage in 14 cases. The specimens of the fistula which extended to the nasopharynx were reported as tracts lined with squamous epithelium (the external part) and ciliated columnar epithelium (the internal part). According to Work's criteria, 9 cases were classified as Type I lesions, 13 cases were classified as Type II lesions, and two special cases could not be classified. The average follow-up was 83 months (ranging from 12 to 152 months). No recurrence was found.

CONCLUSION

First branchial cleft anomalies have high variability in the courses. If a patient is suspected to have first branchial anomalies, the external auditory canal must be examined for the internal opening. CT should be done to understand the extension of the lesion. For cases without internal openings in the external auditory canal, CT fistulography should be done to demonstrate the courses, followed by corresponding treatment. Two special cases might be classified as a new type of lesions.

[Fourth branchial abnormity and management experiences]

OBJECTIVE

To investigate the fourth branchial abnormity and its managements.

METHOD

Twelve cases of the fourth branchial abnormity treated between January 2005 and April 2012 were reviewed.

RESULTS

Dissection of the recurrent laryngeal nerve was done in all cases. Partial thyroidectomy was performed in 10 cases, and 2 cases of them received selective neck dissection including level II, III, IV and VI. The abnormity lesions were found to pass posterior to the thyroid glands in the 10 cases and to pass through the inferior constrictor muscle into the pyriform sinus in 7 cases of them. The internal opening in the pyriform sinus demonstrated by preoperative examination couldn't be identified in the operation in one case. The abnormity tract terminated at the lateral surface of the esophagus in one case, passed into the cervical esophagus in one case, and terminated at the lateral surface of the thyroid gland in one case, and formed a cyst lateral to the thyroid gland in one case. No abnormity tract was found to loop around the hypoglossal nerve and to descend into the mediastinum. The left recurrent laryngeal nerve was cut off in one patient, although end to end anastomosis was performed immediately, the patient was still complicated with left vocal cord paralysis postoperatively. The median follow-up time of the cases was 24 months (8-88 months). One case was lost of follow up. No recurrence was found in 10 cases. Recurrence was found in one case, and no recurrence in 10 cases.

CONCLUSIONS

The presentation of congenital the fourth branchial fistula is variated significantly. Most abnormity lesions had close relations to the thyroid gland and the recurrent laryngeal nerve, thus the recurrent laryngeal nerve need to protect and partial thyroidectomy might be considered. In the recurrent cases when the abnormity couldn't be identified clearly, selective neck dissection including level II, III, IV and VI should be done long term follow up should be carried out in the cases that the internal opening couldn't be found.

[Fourth branchial pouch sinus of children: from diagnosis to techniques and technology of surgical operation]

OBJECTIVE

To clarify the correct diagnostic methods of FBPS of children, and to explore techniques and technology of surgical operation aim to complete excision of sinus tract and preservation of the recurrent laryngeal nerve through analyzing the clinical characteristics and the characteristics of open neck surgery in FBPS of children.

METHOD

Clinical materials of 6 children FBPS with internal pyriform sinus were retrospectively analyzed, and literatures were studied to explore the appropriate surgical management of children FBPS; lesions of 6 patients were completely dissected by open neck surgery with the help of di-direction catheterization revealing the tract of fistula, and the openings of the fistula to pyriform apex were cauterized by monopolar coagulation at the end of the procedure; all 6 cases were with systematic endoscopic follow-up.

RESULT

All cases of 6 children patients were cured by open neck surgery, no recurrence of clinical symptoms were observed during a mean follow-up of 14 months (1-3 years); 2 cases were diagnosed with an "anatomical" relapse (persistence of the sinus tract orifice without clinical symptoms) at the follow-up endoscopy(at 3 and 4 months after surgery); all 6 cases had no complication of laryngeal paralysis.

CONCLUSION

The children patients presenting recurrent acute suppurative thyroiditis and deep neck abscess of anterior area in the lower part of neck, especially locating left neck, should be considered as the diagnosis of FBPS. also the same as confirmed by enhanced neck CT scan and direct laryngoscopy. Patients with identification of internal pyriform sinus and Betz fold by direct laryngoscopy, and with identification of fistula which passes through the cricothyroid membrane beneath the superior laryngeal nerve can be confirmed FBPS. Completely dissection of sinus tract by open neck surgery was the effective management of children FBPS and di direction catheterization aids to reveal and identify the tract of fistula. Resection of the posterior part of the thyroid cartilage ala can be useful to aid exposure and preservation of the recurrent laryngeal nerve; but co-excision of a portion of the upper of the thyroid gland aids to the entire dissection of lesions. In addition, cauterizing the opening of the fistula to pyriform apex may be useful to obliterate the internal opening of pyriform sinus.

Distinct functional and temporal requirements for zebrafish Hdac1 during neural crest-derived craniofacial and peripheral neuron development

The regulation of gene expression is accomplished by both genetic and epigenetic means and is required for the precise control of the development of the neural crest. In hdac1(b382) mutants, craniofacial cartilage development is defective in two distinct ways. First, fewer hoxb3a, dlx2 and dlx3-expressing posterior branchial arch precursors are specified and many of those that are consequently undergo apoptosis. Second, in contrast, normal numbers of progenitors are present in the anterior mandibular and hyoid arches, but chondrocyte precursors fail to terminally differentiate. In the peripheral nervous system, there is a disruption of enteric, DRG and sympathetic neuron differentiation in hdac1(b382) mutants compared to wildtype embryos. Specifically, enteric and DRG-precursors differentiate into neurons in the anterior gut and trunk respectively, while enteric and DRG neurons are rarely present in the posterior gut and tail. Sympathetic neuron precursors are specified in hdac1(b382) mutants and they undergo generic neuronal differentiation but fail to undergo noradrenergic differentiation. Using the HDAC inhibitor TSA, we isolated enzyme activity and temporal requirements for HDAC function that reproduce hdac1(b382) defects in craniofacial and sympathetic neuron development. Our study reveals distinct functional and temporal requirements for zebrafish hdac1 during neural crest-derived craniofacial and peripheral neuron development.

Case series: Endoscopic management of fourth branchial arch anomalies

INTRODUCTION

Fourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery.

OBJECTIVES

To determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute.

METHODS

Retrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively.

RESULTS

In total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO₂ laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11-41 months).

CONCLUSION

Endoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.