Branchial anomalies

Branchial anomalies

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  Branchial anomalies resultfrom improper development of the branchial apparatus
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  Fate of branchialarches
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  Fate of groovesand pouches
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  Fate of pouches
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  Anomalies
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  • Collection offluid in an epithelium-lined sac . • Formed when part of groove or pouch separated and fail to resorb . • lined by : • Contain straw-coloured fluid in which cholesterol crystals are found • Squamous epithelium . • Respiratory epithelium. • 80% have lymphoid tissue in their wall .
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  :  Represent persistenceof both the cleft and the corresponding pouch forming a communication that is epithelial lined.  The fistula lies caudal to the structures derived from that particular arch and connects the skin to the foregut.  Lined by stratified squamous ,columnar , or ciliated epithelium .
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   Blind-ended trackleading from an epithelial surface into deeper tissues (partial fistula)  Occur when groove or pouch fails to resorb
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  Diagnosis • Upper airwayendoscopy • Pharyngeal opening • Tonsillar fossa • Pyriform sinus • FNAC • To clarify the diagnosis • To rule out metastatic CA • Ultrasound • Round mass with uniform low echogenicity and lack of internal septations
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  • Diagnosis CT scan •is first choice investigation • Homogeneous lesion with low attenuation centrally and a smooth enhancing rim MRI • Hypointense on T1 and hyperintense on T2 Fluroscopic or CT fistulography • Inject radioopac dye into the fistula or sinus to delineate course Barium swallow Esophageography • for 3rd and 4th anomalies
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  Treatment • The definitivetreatment is complete surgical excision. • Time for surgery • Early resection to prevent recurrent infections • Acute infection • Systemic antibiotics first • Incision and drainage • Complete resection after resolution
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   Can presentas cysts, sinuses or fistulae located between the EAC and the submandibular area.  Represent 1% of all branchial anomalies  Female > male  Involve EAC or occasionally, the middle ear  Course Close to parotid gland ,superficial lobe.
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  Symptoms:  Otorrhea  Parotidswelling  Mandible pit discharge  Unilateral facial palsy Two types :
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  • Ectodermally derived •Duplication of the external auditory canal (EAC). • immediately anterior ,inferior or posterior to the pinna • course lateral to the facial nerve, .
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  • Ectodermal andmesodermal derived tissues • Terminate in EAC • Behind or below the mandible • Always suprahyaoid • pass medial to the facial nerve • More common than type I
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  Treatment • Standard cervico-mastiod-facialparotidectomy incision with facial nerve dissection and superficial parotidectomy. • Lacrimal probes can help locate tract
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  • Most commonand represent 90-95% of branchial anomalies. • Cyst >fistula • Cysts manifest as smooth , soft masses in the lateral neck located anterior and deep to SCM. • Fistulae tend to manifest as recurrent neck infections following URTI
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  • Mostly diagnosedat 2nd and 3rd decade • Enlarged after URTI • Can cause pressure symptoms • Commonly along the anterior border of SCM. • 4 types :
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  Types of 2ndBCC
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  • Mostly diagnosedin infants • Present with chronic discharge along anterior border of SCM .
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  TRACT
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  Treatment • Transverse incisionover skin fold • Transvers elliptical incision made around the external opening and the tract identified
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  Treatment • surgeon mustdissect around the cyst bed to exclude associated fistula or tract • Exploration of associated tract with complete excision • Monofilament or probe to cannaulate the fistula tract • Finger assisted to identify internal opening in tonsillar fossa
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  Treatment • The tractmust be carefully ligated and divided at its entry into the fossa • The spinal accessory, hypoglossal, and vagus nerves must identified to be protected from injury during the dissection. • Cysts lying medial to carotid sheath are more easily approached trans-orally
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  • Very Rare •Mid or lower anterior border of SCM and at the level of superior pole of thyroid • Internal Opening to pyriform fossa • This anomaly is also closely related to the thyroid gland, which when inflamed, may cause thyroiditis. • Enlarged rapidly after URTI
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  • Extremely rare •A lateral cervical cyst with an internal Opening in the pyriform sinus is a common occurrence . • mostly in children • In neonatal :present as lateral neck mass or abscess with obstructive airway symptoms • In children or adult: recurrent lateral neck abscess and recurrent suppurative thyroiditis .
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  Treatment  External approach Excision of the tract with endoscopic assissted cannaulation.  Ligation and dividing the tract  Ipsilateral hemithroidectomy with partial resection of thyroid cartilage for 4th pouch anomaly  Internal approach  Endoscopic electric cauterization  Endoscopic chemical cauterization with silver nitrate
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   Permanent recurrentlaryngeal nerve palsy.  Post operative pharyngocutaneous fistula  Hypoglossal nerve palsy. Complications