BRANCHIAL TRACT ANOMALIES / HEAD AND NECK SWELLINGS CONGENITAL ANOMALIES

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

4. Fate of branchial arches

5. Fate of grooves and pouches

6. Fate of pouches

7. Anomalies

8. • 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. :
 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.  Blind-ended track leading from an epithelial
surface into deeper tissues (partial fistula)
 Occur when groove or pouch fails to resorb

11. 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. • 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 3rd and 4th anomalies

13. 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.  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. Symptoms:
 Otorrhea
 Parotid swelling
 Mandible pit discharge
 Unilateral facial palsy
Two types :

16. • Ectodermally derived
• Duplication of the external
auditory canal (EAC).
• immediately anterior ,inferior or
posterior to the pinna
• course lateral to the facial nerve,
.

17. • 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

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

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

23. Types of 2nd BCC

24. • Mostly diagnosed in
infants
• Present with chronic
discharge along anterior
border of SCM .

25. TRACT

27. Treatment
• Transverse incision over skin fold
• Transvers elliptical incision made around the external opening and the
tract identified

28. 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. 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. • 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

33. • 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 .

36. 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

37.  Permanent recurrent laryngeal nerve palsy.
 Post operative pharyngocutaneous fistula
 Hypoglossal nerve palsy.
Complications