Branchial Remnants

Raymond G Buick

Paediatric Surgeon

Birmingham UK

December 2008

Branchial Remnants• First Branchial Cleft Cysts

• Type I– Ectodermal Duplication anomaly of the EAC with

squamous epithelium only.– Parallel to the EAC– Pretragal, post auricular– Connection with TM or Malleus>Incus– Surgical Excision

Branchial Remnants• First Branchial Cleft Cysts

• Type II– Ectoderm and mesoderm components– Anterior neck, superior to hyoid bone.– Courses over the mandible and through the parotid in variable

position to the Facial Nerve.– Terminates near the EAC bony-cartilaginous junction.– Surgical excision- superficial parotidectomy

REFER TO ENT

Branchial Remnants

preauricularsinus

Preauricular sinus• The External Ear forms from a

number of tubercles.• Failure of normal fusion may

result in a congenital sinus• Pinpoint opening• Maybe short symptomless

tract• May lead to a ‘rabbit warren’ of

intercommunicating cysts in front of the tragus

• ? ENT

Preauricular pits

• Infected preauricular pit

• Preauricular abscess

Branchial Remnants• SKIN TAGS• These are most often benign, isolated minor anomalies,

• mostly unilateral but occasionally bilaterally.

• It is important however to examine the anatomic landmarks carefully. If the tags are associated with distortion of the pinna then it should trigger suspicion of associated pathology such as the possibility of hemifacial microsomia.

• Tags may also be seen as part of multiple dysmorphic features of infants with chromosomal anomalies.

• if isolated, no investigations are required and audiology referral is not necessary unless there are other risk factors, particularly a family history of hearing loss.

Branchial Remnants• SKIN TAGS

Cartilaginous Remnants

Branchial Remnants• Second Branchial Cleft Cysts

• Most Common (90%) branchial anomaly• Classical Branchial cysts & sinuses

Branchial Cyst• At the fourth week of embryonic life, the development of 4

branchial (or pharyngeal) clefts results in 5 ridges known as the branchial (or pharyngeal) arches, which contribute to the formation of various structures of the head, the neck, and the thorax.

• The second arch grows caudally• Branchial cysts arise from failure of obliteration of the second

branchial cleft in embryonic development.

Branchial CystBranchial cleft cysts are congenital epithelial cysts

Present on the lateral part of the neck

Branchial CystBranchial cleft cysts are congenital epithelial cysts

Present on the lateral part of the neck

Painless, fluctuant mass in anterior triangle often behind SCM muscle

Branchial CystBranchial cleft cysts are congenital epithelial cysts

Present on the lateral part of the neck

Painless, fluctuant mass in anterior triangle often behind SCM muscle

Sinus / fistula on anterior border of SCM at junction of middle and lower 1/3 Often VERY tiny

Sinus orfistula Sinus or

fistula

Branchial Cyst• A branchial cyst commonly presents as a solitary, painless

mass in the neck of a child or a young adult. A history of intermittent swelling and tenderness of the lesion during upper respiratory tract infection may exist. Discharge may be reported if the lesion is associated with a sinus / fistulus tract.

• In some instances, patients may present with locally compressive symptoms.

• A family history may be present.

Branchial Cyst

• Most branchial cysts are asymptomatic. They may become tender, enlarged, or inflamed, or they may develop abscesses, especially during periods of upper respiratory tract infection, due to the lymphoid tissue located beneath the epithelium.

• Spontaneous rupture of an abscessed branchial cleft cyst may result in a purulent draining sinus to the skin or the pharynx.

Branchial Remnants• Second Branchial Cleft Cysts

Branchialfistula

Branchial Fistulaorifice inTonsillar fossa

Branchial Cyst

• Treatment• Surgical Excision

Antibiotics for infected lesions- excisionI & D may be needed initially

Ladder incision may be neededdeep to platysma, lateral to IX, X, XII, between the internal and external carotidterminate in the tonsillar fossa

Branchial Remnants• THANKS TO • www.adhb.govt.nz