July 13, 2009 | In: PEDIATRIC SURGERY
88 CONGENITAL CYSTS AND SINUSES OF THE NECK
Frederick M. Karrer M.D., Denis D. Bensard M.D.
1. What are branchial cleft anomalies?
Show answer
Cysts, sinuses, and fistulas that result from incomplete obliteration of the first, second, or third branchial clefts, and are present in early fetal development.
2. Which anomaly is the most common?
Show answer
Second branchial cleft anomalies are by far the most common, presenting near the mid- to upper border of the sternocleidomastoid (SCM) muscle. First branchial remnants are less common and third clefts are quite rare. (See Table 88-1.)
Table 88-1. BRANCHIAL CLEFT ANOMALIES
|
Branchial Cleft
|
Internal Opening
|
Exterior Opening
|
Frequency
|
|
First
|
External auditory canal
|
Angle of the jaw
|
8%
|
|
Second
|
Tonsillar fossa
|
Anterior border of the SCM
|
> 90%
|
|
Third
|
Piriform sinus
|
Suprasternal notch
|
< 1%
|
3. How do patients with branchial cleft anomalies present?
Show answer
Those with complete fistulas or sinuses present with intermittent drainage of a mucoid fluid on the neck. Patients with cysts usually present later with a mass (sterile or infected). Complete surgical excision is the treatment of choice.
4. What are the major operative hazards of branchial cleft remnant excision?
Show answer
The second branchial cleft tracts through the bifurcation of the carotid artery. The facial nerve is in close proximity to the first branchial cleft fistula. The superior laryngeal nerve and the recurrent laryngeal nerve are both at risk in dissection of a third branchial cleft.
5. What is a thyroglossal duct cyst?
Show answer
A thyroglossal duct cyst is the most common congenital cyst found in the neck. It is caused by failure of normal obliteration of the migration tract of the thyroid gland. Embryologically, the thyroid descends from the base of the tongue (foramen caecum) to its normal location in the low anterior neck.
6. How do patients with thyroglossal duct cysts present?
Show answer
They present with a paramidline mass in the upper neck; if infected, they may present with fever, tenderness, and erythema.
KEY POINTS: CONGENITAL CYSTS AND SINUSES OF THE NECK
1. The most common brachial cleft anomaly is the second brachial cleft anomaly presenting near the mid- to upper border or the sternocleidomastoid muscle.
2. A thyroglossal duct cyst is the most common congenital cyst found in the neck.
3. A cystic hygroma is a congenital lymphatic malformation that is benign an usually presents as a soft mass in the lateral neck.
7. How are thyroglossal duct cysts treated?
Show answer
The best treatment is complete excision of the cyst, along with the tract. Because embryologically the thyroid descends before formation of the hyoid cartilage, the tract may pass right through the hyoid. Therefore, complete tract removal requires excision of the central portion of the hyoid and dissection up to the base of the tongue (i.e., the Sistrunk procedure).
8. What is a cystic hygroma?
Show answer
A cystic hygroma is a congenital lymphatic malformation with a predilection for the neck. It is a benign lesion that usually presents as a soft mass in the lateral neck. Excision is often challenging because the lymph cysts do not respect the fascial planes and often intertwine with the neurovascular structures in the neck. Near-total excision is the treatment of choice.
References
BIBLIOGRAPHY
1. Alqahtani A, Nguyen LT, Flageole H, et al: 25 years experience with lymphangioma in children. J Pediatr Surg 34:1164-1168, 1999. Medline Similar articles Full article
2. Brown RL, Azizkhan RG: Pediatric head and neck lesions. Pediatr Clin North Am 45:889-905, 1998. Medline Similar articles
3. Kang L, Chang CH, Yu CH, et al: Prenatal detection of cystic hygroma using three-dimensional ultrasound. Ultrasound Med Biol 28:719, 2002. Medline Similar articles
4. Organ GM, Organ CH Jr: Thyroid gland and surgery of the thyroglossal duct: Exercise in applied embryology. World J Surg 24:886-890, 2000.
5. Smith CD: Cysts and sinuses of the neck. In O’Neill JA, Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery, 5th ed. St. Louis, Mosby, 1998, pp 757-771.
6. Telander RL, Filston HC: Review of head and neck lesions in infancy and childhood. Surg Clin North Am 72:1429-1447, 1992. Medline Similar articles
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