Branchial anomalies

BRANCHIAL TRACT ANOMALIES /
HEAD AND NECK SWELLINGS
CONGENITAL ANOMALIES

1. Branchial tract anomalies DR.MAMOON Ameen

2. Branchial tract anomalies Branchial anomalies result from improper development of the branchial apparatus

3. Branchial tract anomalies Branchial apparatus

4. Branchial tract anomalies Fate of branchial arches

5. Branchial tract anomalies Fate of grooves and pouches

6. Branchial tract anomalies Fate of pouches

7. Branchial tract anomalies Anomalies

8. 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 .

9. 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 .

10. 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

11. Branchial tract anomalies Diagnosis 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

12. Branchial tract anomalies 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 3 rd and 4 th anomalies

13. Branchial tract anomalies Treatment 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

14. 1 st 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.

15. 1 st Branchial Anomalies Symptoms: Otorrhea Parotid swelling Mandible pit discharge Unilateral facial palsy Two types :

16. 1 st 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, .

17. 1 st 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

18. 1 st Branchial Anomalies

19. 1 st Branchial Anomalies

20. 1 st Branchial Anomalies Treatment Standard cervico - mastiod -facial parotidectomy incision with facial nerve dissection and superficial parotidectomy . Lacrimal probes can help locate tract

21. 2 nd 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

22. 2 nd Branchial Anomalies cyst Mostly diagnosed at 2 nd and 3 rd decade Enlarged after URTI Can cause pressure symptoms Commonly along the anterior border of SCM. 4 types :

23. 2 nd Branchial Anomalies Types of 2 nd BCC

24. 2 nd Branchial Anomalies Fistula Mostly diagnosed in infants Present with chronic discharge along anterior border of SCM .

25. 2 nd Branchial Anomalies TRACT

26. 2 nd Branchial Anomalies

27. 2 nd Branchial Anomalies Treatment Transverse incision over skin fold Transvers elliptical incision made around the external opening and the tract identified

28. 2 nd 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

29. 2 nd 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

30. 3 rd 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, which when inflamed, may cause thyroiditis. Enlarged rapidly after URTI 3 rd BBC can be presented in posterior cervical triangle May enlarged rapidly after URTI

31. 3 rd Branchial Anomalies

32. 3 rd Branchial Anomalies

33. 4 th 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 .

34. 4 th branchial anomalies

35. 4 th branchial anomalies

36. 3 rd and 4 th 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 4 th pouch anomaly Internal approach Endoscopic electric cauterization Endoscopic chemical cauterization with silver nitrate

37. 3 rd and 4 th branchial anomalies Permanent recurrent laryngeal nerve palsy. Post operative pharyngocutaneous fistula Hypoglossal nerve palsy. Complications

38. Branchial tract anomalies

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