Embryonic development of the head and neck: part 2, the branchial region

Neonatal Presentation of an Air-Filled Neck Mass that Enlarges with Valsalva: A Case Report

Branchial cleft cysts are common causes of congenital neck masses in the pediatric population. However, neonatal presentation of branchial cleft cysts is uncommon, but recognizable secondary to acute respiratory distress from airway compression or complications secondary to infection. We report a 1-day-old infant presenting with an air-filled neck mass that enlarged with Valsalva and was not associated with respiratory distress. The infant was found to have a third branchial cleft cyst with an internal opening into the pyriform sinus. The cyst was conservatively managed with endoscopic surgical decompression and cauterization of the tract and opening. We review the embryology of branchial cleft cysts and current management.

First branchial cleft anomaly: clinical insight into its relevance in otolaryngology with pediatric considerations

First branchial cleft anomalies (FBCA) represent a small subset of congenital malformations in neck. Prime objective of this study is to share our experience with FBCA, emphasize its relevance in otolaryngology and deal with its pediatric perspective. Embryology, pathologic anatomy and varied spectra of clinical presentations of FBCA are discussed. Along with this we have illustrated three different cases; all of them were of pediatric age group and were misdiagnosed by their treating specialists elsewhere. In this article we have also laid special emphasis on its pediatric considerations. FBCA are mostly misdiagnosed due to their unfamiliar clinical signs and symptoms. Swellings may masquerade as other neck masses. Majority of patients give a history of previous incision and drainage. While dealing with pediatric patients the important factors to be kept in mind are the age of child, superficial course of facial nerve, any associated agenesis of parotid gland. Alteration in surgical technique may be required in children. A thorough medical examination with high index of clinical suspicion should be kept in mind while dealing with such anomalies. Owing to their complex presentation and close relation with facial nerve they are challenging lesions for surgeons.

Recurrent thyroid abscess - Is it a fourth branchial archanomaly?

Branchial fistulae are of congenital origin(6) and consists of skin lined tract opening internally at junction of cartilaginous and bony meatus in case of 1(st) arch anomaly, tonsillar fossa in case of 2(nd) arch, while 3(rd) and 4(th) arch sinuses have internal opening at level of pyriform sinus or below. A complete tract of 3(rd) or 4(th) arch fistulae is yet to be described. Fourth arch fistulae(1) have a distinct clinical pattern of internal opening at pyriform apex, are left sided and associated with suppurative thyroiditis(3), they manifest at a younger age and treatment involves excision of tract with ipsilateral thyroid lobectomy.

Cystic malformations of the neck in children

The most common cystic malformations of the neck are the result of abnormal embryogenesis involving the thyroglossal duct (TGD), lymphatic primordia and the branchial apparatus. When the basic embryology of these structures is considered, a reasonable differential diagnosis-and in some cases a definitive diagnosis-can be achieved based on the location and the imaging characteristics of the cystic mass.

Fistula of the fourth branchial pouch

Most of the congenital anomalies of the branchial apparatus are from the second arch, pouch, and cleft; some are from the first and third arches. Fourth branchial pouch remnants are very rare. We present a rare case of fourth branchial fistula, with characteristic clinical features of recurrent left-sided neck abscess that burst spontaneously, forming a fistula. Diagnosis of fourth branchial pouch fistula was confirmed by contrast radiography (ie, fistulogram and barium swallow) revealing the internal opening in the apex of the left pyriform fossa.

Head and neck anomalies related to the branchial apparatus

An understanding of the branchial apparatus and its anomalies may lead to greater precision in the clinical diagnosis and management of these congenital head and neck lesions. Although branchial anomalies have been well described, controversial issues, such as the branchial origin of lateral cervical cysts and the differentiation between third and fourth branchial pouch sinuses, remain unresolved.

Fourth branchial sinus causing recurrent cervical abscess

BACKGROUND

Three patients who presented with recurrent cervical abscesses were found to have a branchial sinus arising in the piriform fossa. Each patient had previously had cervical abscess drainage procedures.

METHODS

A retrospective review of patients with recurrent cervical abscess and associated fourth branchial sinus was carried out.

RESULTS

In each case, imaging and endoscopy identified a sinus tract from the left piriform fossa. Neck exploration with hemithyroidectomy and excision of the sinus tract was performed without further recurrence of abscess.

CONCLUSIONS

We believe these cases to represent a fourth branchial sinus. The relevant embryology and anatomy of the branchial apparatus is discussed and the pathways for the sinus and fistulous tracts of branchial sinus origin are reviewed. Branchial sinuses are uncommon, but should be considered as the underlying aetiology in patients who present with recurrent cervical abscesses.

Intrathyroidal lymphoepithelial cysts of probable branchial origin

Lymphoepithelial cysts with histological features characteristic of branchial cleft cysts have been reported to occur rarely in the thyroid gland. To our knowledge only six cases of this lesion have been reported. Since these reports brought this entity to our attention, we have noted that intrathyroidal lymphoepithelial cysts are not rare lesions. We report six further cases; four were incidental histological findings, and two lesions were clinically detected masses. Each of the cysts had a squamous epithelial lining with abundant underlying lymphoid tissue, including lymphoid aggregates with large reactive germinal centers. All cases were associated with chronic lymphocytic thyroiditis. Because of the histological resemblance to branchial cleft cysts, it is postulated that these lymphoepithelial cysts are branchial in origin. The histogenesis of branchial cleft cysts is unknown; however, the ultimobranchial body, originating from branchial pouches four and/or five, contributes to the embryological development of the thyroid. Branchial cleft derivatives, such as thymus and parathyroid, develop in close association with the thyroid and may be found within the thyroid gland. These branchial cleft-like cysts also may arise from branchial cleft derivatives, and their enlargement may be related to the immunological mechanisms associated with autoimmune thyroiditis.

An intra-thyroidal branchial cyst: a case report

Branchial cleft cysts were previously thought not to occur in the thyroid but have recently been described in two patients with Hashimoto's disease. This case report describes a patient with a branchial cleft cyst in an otherwise normal thyroid gland and could provide further evidence that thyroidal follicular cells are derived from the branchial clefts as well as from the primitive gut.

Tumors of the neck showing thymic or related branchial pouch differentiation: a unifying concept

A number of rare tumors occurring in the soft tissues of the neck and the thyroid gland, reported in the literature under a variety of designations, show complete to partial histologic resemblance to the fetal, mature, or involuted thymus and mediastinal thymomas. This family of tumors spans a range of histologic appearances and behaviors from completely benign lesions to metastasizing malignant tumors. After reviewing the previously reported and new cases, we have been able to delineate four reasonably well-defined clinicopathologic entities within this spectrum. On the benign end is "ectopic hamartomatous thymoma," which occurs in the soft tissues of the lower neck. It is characterized by spindle epithelial cells, solid or cystic epithelial islands, and adipose cells which intermingle haphazardly to impart a hamartomatous quality. In the middle of the spectrum are the ectopic cervical thymomas which are usually benign, but can sometimes be locally invasive and can exceptionally metastasize. They are histologically identical to mediastinal thymomas, and residual ectopic thymus is not uncommonly identifiable in the periphery of the tumor. On the malignant end are tumors we have designated as "spindle epithelial tumor with thymus-like differentiation" (SETTLE) and "carcinoma showing thymus-like differentiation" (CASTLE). Tumors of the SETTLE type occur in the thyroid gland of young patients, and are highly cellular tumors comprised of compact bundles of long spindle epithelial cells which merge with tubulopapillary structures and/or mucinous glands. Tumors of the CASTLE type are histologically similar to thymic carcinoma of the lymphoepithelioma or squamous cell variety. We postulate that this family of tumors arises either from ectopic thymus or remnants of branchial pouches which retain the potential to differentiate along the thymic line.