Branchial anomalies

Branchial tract anomalies

DR.MAMOON Ameen

Branchial tract anomalies

Branchial anomalies result from improper development of the branchial apparatus

Branchial tract anomaliesBRANCHIAL APPARATUS

Branchial tract anomaliesFate of branchial arches

Branchial tract anomaliesFate of grooves and pouches

Branchial tract anomaliesFate of pouches

Branchial tract anomaliesAnomalies

Branchial tract anomalies

Cyst • Collection of fluid 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 .

Branchial tract anomalies

Fistula: Represent persistence of 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 .

Branchial tract anomalies Sinus:

Blind-ended track leading from an epithelial surface into deeper tissues (partial fistula)

Occur when groove or pouch fails to resorb

Branchial tract anomaliesDiagnosis

• Upper airway endoscopy• 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

Branchial tract anomalies• DiagnosisCT scan • is first choice investigation• Homogeneous lesion with low attenuation centrally and a smooth

enhancing rim

MRI • Hypointense on T1 and hyperintense on T2Fluroscopic or CT fistulography • Inject radioopac dye into the fistula or sinus to delineate course

Barium swallow Esophageography • for 3rd and 4th anomalies

Branchial tract anomaliesTreatment • The definitive treatment 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

1ST BRANCHIAL ANOMALIES

Can present as 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.

1ST BRANCHIAL ANOMALIES

Symptoms: Otorrhea Parotid swelling Mandible pit discharge Unilateral facial palsy

Two types :

1ST BRANCHIAL ANOMALIES

TYPE I• Ectodermally derived

• Duplication of the external auditory canal (EAC).

• immediately anterior ,inferior or posterior to the pinna

• course lateral to the facial nerve, .

1ST BRANCHIAL ANOMALIES

Type II • Ectodermal and mesodermal

derived tissues• Terminate in EAC• Behind or below the mandible • Always suprahyaoid• pass medial to the facial nerve• More common than type I

1ST BRANCHIAL ANOMALIES

1ST BRANCHIAL ANOMALIES

1ST BRANCHIAL ANOMALIES

Treatment• Standard cervico-mastiod-facial parotidectomy incision

with facial nerve dissection and superficial parotidectomy.

• Lacrimal probes can help locate tract

2ND BRANCHIAL ANOMALIES

• Most common and 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

2ND BRANCHIAL ANOMALIES

cyst • Mostly diagnosed at 2nd

and 3rd decade • Enlarged after URTI • Can cause pressure

symptoms • Commonly along the

anterior border of SCM.• 4 types :

2ND BRANCHIAL ANOMALIES

Types of 2nd BCC

2ND BRANCHIAL ANOMALIES

Fistula • Mostly diagnosed in

infants • Present with chronic

discharge along anterior border of SCM .

2ND BRANCHIAL ANOMALIES

TRACT

2ND BRANCHIAL ANOMALIES

2ND BRANCHIAL ANOMALIES

Treatment• Transverse incision over skin fold • Transvers elliptical incision made around the external opening and the

tract identified

2ND BRANCHIAL ANOMALIES

Treatment

• surgeon must dissect 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

2ND BRANCHIAL ANOMALIES

Treatment

• The tract must 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

3RD BRANCHIAL ANOMALIES

• 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, whichwhen inflamed, may cause thyroiditis.

• Enlarged rapidly after URTI

• 3rd BBC can be presented in posterior cervical triangle • May enlarged rapidly after URTI

3RD BRANCHIAL ANOMALIES

3RD BRANCHIAL ANOMALIES

4TH BRANCHIAL ANOMALIES

• 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 .

4TH BRANCHIAL ANOMALIES

4TH BRANCHIAL ANOMALIES

3RD AND 4TH BRANCHIAL ANOMALIES

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

3RD AND 4TH BRANCHIAL ANOMALIES

Permanent recurrent laryngeal nerve palsy. Post operative pharyngocutaneous fistula Hypoglossal nerve palsy.

Complications

Branchial tract anomalies

THANK YOU