Common congenital anomalies of the neck. Embryology and surgical anatomy

Evaluation of preoperative cutaneous fistula as a risk factor for recurrence of thyroglossal duct cyst in children

The aim of this study is to investigate the risk factors for recurrence after thyroglossal duct cyst (TGDC) surgery, differentiating between infections with and without a cutaneous fistula. This is a retrospective analysis of all paediatric TGDC in a tertiary care centre with at least 2 years of postoperative follow-up. One hundred and thirty-one patients met the inclusion criteria of the study. A multivariate analysis was performed to analyse the main risk factors for recurrence (presence of a fistula, infection, age). 116/131 patients were managed primarily in our institution; 15 patients had previously been operated on in another centre. The recurrence rate was 4.3% (5/116) when the patient was operated on in our institution at the first operation, and overall, recurrence of TGDC occurred in 20/131 (15.3%) patients. Age was not a risk factor for recurrence (p = 0.596). Two or more episodes of preoperative TGDC infection were a statistically significant risk factor in univariate analysis (p = 0.021) but not in multivariate analysis adjusted for age and the presence of a cutaneous fistula (p = 0.385). In multivariate analysis, cutaneous fistula formation was an independent risk factor for recurrence when adjusted for age and preoperative TGDC infection (Hazard ratio = 5.35; p = 0.011).

CONCLUSIONS

A preoperative cutaneous fistula was a critical and independent risk factor for recurrence of operated TGDC, whereas age and TGDC infection were not identified as risk factors for recurrence after surgery. This information should be given to patients and parents before surgery.

WHAT IS KNOWN

• The risk factors for recurrence after thyroglossal duct cyst surgery described in the literature are preoperative infection and young age, but this is not supported by strong evidence. • The role of cutaneous fistula formation is unclear.

WHAT IS NEW

• The main risk factor for recurrence of TGDC is the presence of a preoperative cutaneous fistula, with an estimated hazard ratio of 4.95 (p = 0.016) in multivariate analysis. • The presence of two preoperative infections was also associated with a greater risk of recurrence in univariate analysis; age and gender were not associated with an increased risk of recurrence.

Internal Hypopharyngeal Cyst: A Review of Literature

Detailed information on the hypopharyngeal cyst presentation, terminology, classification, diagnosis, management, and possible complication is scarce though it would lead to life-threatening symptoms. This review article, therefore, meticulously presents and analyzes the majority of the pertaining literature. In this context, a particular emphasis has been placed on the embryological development of the branchial arches while discussing each entity that would improve the current understanding of different pharyngeal cyst's pathologies.

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part I. Normal Developmental Anatomy (Embryogenesis) for the Surgeon

Knowledge of the embryogenesis of the pharyngeal apparatus is the only means of understanding the “architecture” of the neck. The embryonic pharynx (which includes future oral and nasal cavities) is a much more extensive area than the adult pharynx. The main feature of the developing pharynx is a series of arches, internal pouches, and external clefts, which together comprise the pharyngeal apparatus. This structure is associated with other developing splanchna of the neck, e.g., the thyroid and parathyroid glands, tonsils, and thymus. Within each of the pharyngeal arches are the developing aortic arches and, specific for each arch, cranial nerves. The complex relations of the mesenchymal derivatives of arches (muscles, cartilage, bones) with the neurovascular bundles within each arch are presented and explained. The pharyngeal apparatus undergoes dramatic transformations: pouches and clefts disappear without interruption (interruption would produce gills and support the misnomer “branchial apparatus”). In addition, in the lateroventral neck, somites migrate to produce other muscles such as sternocleidomastoid and trapezius innervated by spinal nerves. Lateral congenital anomalies largely rely on persistence of a cleft/and or pouch or communication between the two. Their tracts have a “crooked” course among other entities generated by alterations that take place during embryogenesis.

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

“Anatomy of the abnormal”—a branch of surgical anatomy—deals with relations of an anomaly to surrounding entities. Here, lateral congenital anomalies of the pharyngeal apparatus are examined; their relations to entities of the neck can be explained embryologically. Location of embryonic pharyngeal arches, clefts, and pouches in the adult is presented and terminology of these anomalies (fistulas, sinuses, cysts) is defined. First “cleft and pouch” anomalies relate with the parotid and facial nerve. Second cleft and pouch anomalies course deeply to second arch structures and superficially to third arch structures. Consequently, they relate with hypoglossal and glossopharyngeal nerves and internal and external carotid arteries. Third cleft and pouch anomalies pass deep to third arch entities and superficial to those of the fourth arch and relate with glossopharyngeal, hypoglossal, superior and recurrent laryngeal nerves, and the internal carotid artery. The complicated course of fourth cleft and pouch anomalies brings them into relationship with glossopharyngeal, hypoglossal, superior and recurrent nerves, internal carotid, aorta, and subclavian arteries. Found superficially are veins (external and anterior jugular, common facial, communicating), nerves (transverse cervical, great auricular, mandibular, cervical branches of facial), and relevant spinal nerves (e.g., accessory). Knowledge of these anatomical relations helps prevent anatomical complications.

Selective pathologies of the head and neck in children: a developmental perspective

The range of pathology seen in the head and neck region is truly amazing and to a large extent probably mirrors the complex signaling pathways and careful orchestration of events that occurs between the primordial germ layers during the development of this region. As is true in general for the entire discipline of pediatric pathology, the head and neck pathology within this age group is as diverse and different as its adult counterpart. Cases that come across the pediatric head and neck surgical pathology bench are more heavily weighted toward developmental and congenital lesions such as branchial cleft anomalies, thyroglossal duct cysts, ectopias, heterotopias, choristomas, and primitive tumors. Many congenital "benign" lesions can cause significant morbidity and even mortality if they compress the airway or other vital structures. Exciting investigations into the molecular embryology of craniofacial development have begun to shed light on the pathogenesis of craniofacial developmental lesions and syndromes. Much more investigation is needed, however, to intertwine aberrations in the molecular ontogeny and development of the head and neck regions to the represented pathology. This review will integrate traditional morphologic embryology with some of the recent advances in the molecular pathways of head and neck development followed by a discussion of a variety of developmental lesions finishing with tumors presumed to be derived from pluripotent/progenitor cells and tumors that show anomalous or aborted development.

Papillary carcinoma of a thyroglossal duct cyst in a patient with thyroid hemiagenesis: effectiveness of conservative surgical treatment

OBJECTIVE

To describe a case of thyroglossal duct cyst carcinoma that arose in a patient with right thyroid lobe hemiagenesis.

METHODS

We present the imaging, physical examination findings, treatment, and clinical course of the study patient.

RESULTS

A 35-year-old woman was evaluated for a neck mass that had been present for 6 months and was slowly growing. She reported a previous diagnosis of right hemithyroid agenesis. The patient's preoperative workup included ultrasonography of the neck and head and neck T1- and T2-weighted magnetic resonance imaging, which showed right hemithyroid agenesis and a cystic lesion in the median region of the neck below the hyoid bone. Findings from chest x-rays and thyroid function tests were normal. The patient underwent a modified Sistrunk procedure that included removal of the median portion of the hyoid bone. Histologic findings showed a 2.5-cm thyroglossal duct cyst with a 0.6-cm focus of follicular variant of papillary carcinoma with invasion of the cyst wall. Total thyroidectomy was not performed because of the absence of tumoral invasion of the parenchyma around the thyroglossal duct cyst and because the patient was at low risk for aggressive disease. Cervical ultrasonography examinations were performed 6, 12, and 24 months after treatment, and all findings were normal. Presently, the patient is symptom-free after 4 years of follow-up and has no evidence of disease.

CONCLUSION

Incidentally discovered, well-differentiated thyroid cancer that is confined to a thyroglossal duct cyst in a patient at low risk for aggressive disease can be adequately treated by a modified Sistrunk procedure that includes the median portion of the hyoid bone.

Sonographic assessment of thyroglossal duct cysts in children

OBJECTIVE

The purpose of this study was to clarify the sonographic features of thyroglossal duct cysts (TDCs) in children. We also investigated how the presence of inflammation influences the sonographic appearance.

METHODS

We reviewed the sonograms from 36 children (0.5-14 years old) with pathologically proven TDCs. The lesions were evaluated for location, shape, internal echo pattern, internal septa, wall thickness, posterior enhancement, solid components, margins, and fistulas. The sonographic features of 7 lesions that pathologically showed inflammation were also investigated.

RESULTS

Most TDCs were midline (77.8%), were located at the hyoid bone (44.4%) or were infrahyoid (38.9%), showed posterior enhancement (77.8%), were unilocular (86.1%), lacked internal septa (91.7%), and had a thin wall (75%). None had a solid component. The internal echo patterns were classified into 4 types: anechoic (25%), homogeneously hypoechoic (16.7%), pseudosolid (16.7%), and heterogeneous (41.6%). Inflammation was confirmed in 78% of the lesions with wall thickening and 100% of the lesions with internal septa.

CONCLUSIONS

Most TDCs in children had echogenicity ranging from hypoechoic to heterogeneous. A thick wall and internal septa were considered to correlate with the presence of inflammation but not with the internal echo patterns of TDCs.

Assessment of origin characteristics of the front branches of the external carotid artery

The neck region has a great vital value; its variations and known micrometric values are accepted as important orientation points during intervention. Micrometric values of the front branches of the external carotid artery and their relations to the surrounding structures and metric data pertaining to origin locations of the superior thyroid (STA), lingual (LA), and facial (FA) arteries were evaluated in 40 samples. As regards the evaluation of the branching types of the external carotid artery, the cases where the STA, LA, and FA originated as separate branches were 90%, linguofacial trunk cases were 7.5%, and thyrolingual trunk cases were 2.5%. The diameters of the STA, LA, and FA at their origins were observed to be 3.53 +/- 1.17, 3.06 +/- 0.65, and 3.35 +/- 0.68 mm, respectively. The distances from the origin of the STA to the carotid bifurcation of 3.29 +/- 4.27 mm, origin of the STA to that of the LA of 10.45 +/- 5.16 mm, and origin of the STA to that of the FA of 18.20 +/- 8.81 mm were found. The current findings may have serious implications for radiologic examinations, exploration of the neck, thyroid and parathyroid surgery, tracheotomy, and surgery of the larynx, pharynx, upper esophagus, pterygopalatine, and infratemporal fossa.

Branchial cleftlike cysts of the thyroid

Branchial cleftlike cysts of the thyroid gland are rare lesions. Although initially described in patients with chronic lymphocytic thyroiditis, these cysts have been reported in a variety of histologic settings. We present 2 case studies, 1 in a 30-year-old woman and 1 in a 50-year-old man. The mode of presentation and management of these cases, along with a literature review, is discussed in brief.

Lumps and bumps in neonates and infants

There are many developmental abnormalities that may appear in the neonate and in infants when critical steps in embryogenesis fail. These steps are often not fatal but can lead to significant morbidity for those patients affected. A logical approach is needed in addressing both the diagnostic and therapeutic issues that arise when caring for these patients, as various lesions will warrant an observational approach, and others may require imaging studies or definitive surgical intervention. Additionally, there are other "lumps and bumps" that are seen in the neonatal and infantile age groups that include malignancies and cutaneous neoplasms with associated systemic sequelae.

Thyroid transcription factor-1 expression in thyroid-like nasopharyngeal papillary adenocarcinoma: report of 2 cases

We present the cases of 2 pediatric patients with low-grade nasopharyngeal papillary adenocarcinoma with features suggestive of thyroid origin. Both cases showed strong nuclear immunoreactivity for thyroid transcription factor-1 protein and positive immunostaining for cytokeratins 7 and 19. After thyroid imaging studies, local excision was performed in both patients. The patients remain free of disease 2 and 15 years after treatment, with no evidence of lesions in the thyroid or elsewhere.

Simultaneous branchial cleft and thyroid disorders may present a management challenge

BACKGROUND

Cysts, sinuses or abscesses arising from second, third or fourth branchial cleft remnants may lie either within the body of, or in close proximity to the thyroid gland. Given their infrequent nature they may pose both diagnostic and management challenges for the treating surgeon when they occur in association with thyroid disorders.

METHODS

This is a case series. All patients with concomitant thyroid disorders and a branchial cleft anomaly treated in the University of Sydney Endocrine Surgical Unit in the 10-year period 1994-2003 comprised the study group. Patient demographics, clinical presentation, imaging, surgical management, definitive histology and outcomes were documented.

RESULTS

Six patients were identified with an age range of 3-76 years and a male : female ratio of 1:5. Five branchial cleft anomalies were left sided, one was right sided. Two patients had second cleft anomalies, both of which were initially thought to represent metastatic lymph nodes in association with thyroid cancer. A further two patients had third cleft abnormalities presenting as suppurative thyroiditis. The final two patients had fourth cleft abnormalities causing intraoperative management problems.

CONCLUSIONS

Branchial cleft remnants and anomalies are rare but may occur in association with thyroid disease. They may pose a diagnostic and management dilemma either preoperatively, when mistaken for metastatic thyroid cancer, or intraoperatively when mistaken for a thyroid nodule.

Papillary adenocarcinoma of the thyroid in a thyroglossal duct cyst

A case report is presented of an 8-year-old boy who underwent resection of a thyroglossal duct cyst to illustrate a rare, but significant, complication of a common clinical problem. Pathological examination revealed that it contained a papillary adenocarcinoma of the thyroid, presumably arising from ectopic glandular tissue in the cyst. Thyroglossal duct cysts are a common cause of midline neck masses in children. Occult thyroid carcinoma is a rare co-morbid finding. It infrequently leads to death, but thyroglossal duct cysts may also contain the only functioning, albeit ectopic, thyroid tissue. Patients with clinical thyroglossal duct cysts should be carefully evaluated preoperatively for the presence of tumor and other functioning thyroid tissue prior to excision of the cyst.

Lateral cervical cleft: a previously unreported anomaly resulting from incomplete disappearance of the second pharyngeal (branchial) cleft

The authors present a 2-year-old boy with a skin defect located in the right lateral side of the neck. They suggest the defect is a partial failure of disappearance of the second pharyngeal (branchial) cleft and propose a name of lateral cervical cleft.

Thyroglossal Duct Cyst: The New York Eye and Ear Infirmary Experience and a Literature Review

Thyroglossal duct cysts often present in childhood but can also afflict the adult population. In 1920, Sistrunk described surgical management and advocated the removal of the central portion of the hyoid bone, following the cyst tract to the base of the tongue. This surgical technique has not changed since its description 60 years ago. In this paper, a retrospective review of 70 thyroglossal duct cyst excisions performed at the New York Eye and Ear Infirmary from 1988 through 1996 is presented. The patient population consisted of 43 females (61 %) and 27 males (39%). The average age at presentation was 21.5 years, with a range of 18 months to 64 years. The most frequent presenting symptom was a painless midline neck mass. Computed tomography (CT) was the most frequent imaging study performed. Sixty-four patients underwent a Sistrunk procedure while five patients had excision alone. One patient was diagnosed but lost to follow-up. All five patients who underwent simple cystectomy required a second procedure. One patient who underwent the Sistrunk operation required revision. Nine patients had postoperative complications, with recurrence being the most common. We present our experience over an eight-year period.