Branchial Cleft Anomalies

Question 1

A 3-month-old male presents with small pit anterior to the border of the sternocleidomastoid muscle and intermittent mucous drainage. What additional workup or treatment would you advise the parents?

Answer 1

.

Question 2

A 15-year-old female presents with enlarging soft left neck mass. How would you evaluate? Describe the operative management.

Answer 2

.

Question 3

A draining sinus tract is seen below the ear. Describe the appropriate management.

Answer 3

.

Question 4

A 10-year-old boy presents with repeated sore throats, hoarseness, and left anterior neck pain. Further evaluation should include:

Answer 4

.

Question 5

A 14-year-old female with a known right neck cyst presents with acute infection. Describe the most appropriate management.

Answer 5

.

Question 6

What is the most common congenital head and neck lesion?

Answer 6

TGDC

Bronchial anomalies are the second most common

Question 7

What is the most common Branchial anomaly?

Answer 7

Second ~95%
First ~ 1-4%
3/4 - rare

Question 8

Fate of first arch?

Answer 8

External auditory canal

Trigeminal nerve and corresponding muscles

Question 9

Fate of Second arch?

Answer 9

Palatine tonsils
Facial nerve and corresponding muscles
Hyoid bone

Question 10

Presentation of first arch anomalies?

Answer 10

• Cysts sinus or fistula between the external auditory canal and the angle of the mandible.
• cause pain in neck, parotid or ear.
• Chronic otorrhea

Question 11

Second arch presentation?

Answer 11

Cysts, sinus or fistula anterior to the SCM.

Question 12

Presentation of 3/4th anomalies?

Answer 12

Present as recurrent neck infections or abscess.

• Thyroiditis or thyroid cyst
• beware airway compromise/dysphasia
• torticollis

Question 13

What work up is required for branchial anomalies ?

Answer 13

Typically no imaging is required for first and second.

3/4 lesions should have CT or barium swallow to identify tract. Pre-op endoscopy will also help to identify the fistula to the pyriform sinus.

Question 14

Resection of first anomaly?

Answer 14

Type 1 anomalies (ectodermal) pass supro-lateral to facial nerve and typically don’t connect to auditory canal

Type 2 (ectoderm and mesoderm) pass medial to facial nerve and may have tracts that pass between facial N. Branches. May require superficial parotidectomy for removal. Often join the auditory canal.

Question 15

How is a second anomaly excised?

Answer 15

Skin eclipse over cyst or opening. Follow tract towards the pharynx. In the case of type 4 lesions the tract will traverse the bifurcation of the carotid and enter the tonsilar fossa. BEWARE hypoglossal and glossopharyngeal nerves.

Question 16

Excision of third anomaly?

Answer 16

Open over defect near SCM, tract may follow close to thyroid.
Will pass posterior to internal carotid before turning to pass between the bifurcation and the 9/12 nerves.
Follow into the thyroid membrane and ligate at pyriform sinus (endoscopy may help identify)

Almost always on the LEFT side.

Question 17

What the histology seen on Path after excision of branchial anomalies?

Answer 17

Stratified squamous epithelium with lymphocytic inflammation.

Question 18

DDx for BAs?

Answer 18

TGDC
Dermoid
Lymphatic malformation
Parotid cyst

Question 19

Consent points for BAs?

Answer 19

Bleeding, infection (10%), recurrence (up to 20% if any signs of infection), incomplete removal

First- hearing loss, facial droop, (require average of 2-3 surgeries for complete removal with facial nerve injury 10- 40%

2/3 - injury to carotid, tongue deviation, voice hoarseness