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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
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