Branchial Cleft Anomalies Flashcards
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?
.
A 15-year-old female presents with enlarging soft left neck mass. How would you evaluate? Describe the operative management.
.
A draining sinus tract is seen below the ear. Describe the appropriate management.
.
A 10-year-old boy presents with repeated sore throats, hoarseness, and left anterior neck pain. Further evaluation should include:
.
A 14-year-old female with a known right neck cyst presents with acute infection. Describe the most appropriate management.
.
What is the most common congenital head and neck lesion?
TGDC
Bronchial anomalies are the second most common
What is the most common Branchial anomaly?
Second ~95%
First ~ 1-4%
3/4 - rare
Fate of first arch?
External auditory canal
Trigeminal nerve and corresponding muscles
Fate of Second arch?
Palatine tonsils
Facial nerve and corresponding muscles
Hyoid bone
Presentation of first arch anomalies?
- Cysts sinus or fistula between the external auditory canal and the angle of the mandible.
- cause pain in neck, parotid or ear.
- Chronic otorrhea
Second arch presentation?
Cysts, sinus or fistula anterior to the SCM.
Presentation of 3/4th anomalies?
Present as recurrent neck infections or abscess.
- Thyroiditis or thyroid cyst
- beware airway compromise/dysphasia
- torticollis
What work up is required for branchial anomalies ?
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.
Resection of first anomaly?
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.
How is a second anomaly excised?
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.
Excision of third anomaly?
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.
What the histology seen on Path after excision of branchial anomalies?
Stratified squamous epithelium with lymphocytic inflammation.
DDx for BAs?
TGDC
Dermoid
Lymphatic malformation
Parotid cyst
Consent points for BAs?
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
