Efficacy and Safety of Ethanol Ablation for Branchial Cleft Cysts

A Training Course for Simulating Head and Neck Ultrasound-Guided Procedures Using a Gelatin Phantom Model

OBJECTIVES

Ultrasound (US)-guided procedures can be used in the evaluation and treatment of neck masses. However, these procedures need to be practiced before being executed on humans. The aim of this study is to evaluate the efficacy of a training program using a gelatin phantom to practice US-guided procedures.

METHODS

This program included a lecture and practice with a gelatin phantom. We recruited doctors from different hospitals to practice US-guided procedures, including fine-needle aspiration (FNA), core needle biopsy (CNB), percutaneous ethanol injection (PEI), and radiofrequency ablation (RFA). We used a questionnaire with a 5-point scale to evaluate the effectiveness of practicing US-guided procedures under a gelatin phantom.

RESULTS

Forty-four doctors participated, and 37 of them completed the questionnaires. After training, the mean (SD) scores of the doctors were 4.68 (0.47) for "Satisfaction with this course," 4.54 (0.61) for "Ease in practicing FNA&CNB using the phantom," 4.49 (0.61) for "Ease in practicing PEI using the phantom," 4.49 (0.65) for "Ease in practicing RFA using the phantom," and 4.57 (0.55) for "The course effectively familiarizing participants with US-guided procedures." Participants without experience in US examination had higher scores than those with previous US experience, but the difference was not statistically significant.

CONCLUSION

A combination of lectures and hands-on practice of US-guided procedures using a gelatin phantom is an effective educational method for doctors interested in head and neck US. After the training program, doctors gained a better understanding of the necessary steps and skills required for these procedures. They can correctly insert the instruments into the target lesion and perform different US-guided procedures.

Percutaneous injection of sclerosant agents as an effective treatment for cystic malformations of the head and neck

PURPOSE

To evaluate the clinical and aesthetic outcome of percutaneous injection of sclerosant agents to treat head and neck cystic malformations (HNCM) and to assess their recurrence rate based on histology and site.

METHODS

Fifty-four subjects (mean age 46 years) with HNCM treated by percutaneous injection of sclerosant agents between January and December 2017 were included. Imaging and clinical data before and after the procedure were collected. Quality of Life Index, Pain Visual Analogue Scale, and Aesthetic Scale scores were measured to assess clinical and aesthetic outcomes. A size reduction of ≥ 70% assessed through the visual scale was considered significant.

RESULTS

Of the 54 HNCM, there were 26 (48%) lymphatic malformations (LM), 13 (24%) salivary epithelial duct cysts of the parotid gland, 12 (22%) salivary mucoceles, and 3 (5%) branchial cysts. A significant size reduction and a satisfactory clinical-aesthetic outcome were observed in all types of LM. The number of reinterventions was significantly associated with the number of lesions (p < 0.001). The lowest number of interventions was observed in macrocystic lymphatic malformations (average of 1.2 interventions). All salivary epithelial duct cysts showed a significant reduction in size, a satisfactory clinical-aesthetic outcome, and an average of 1.16 interventions per patient. Mucoceles had a worse response, with only 3/14 patients showing a satisfactory and long-lasting clinical outcome (average of 1.16 interventions). Treatment of branchial cysts showed the worst outcome with a limited clinical response (3/3).

CONCLUSION

Percutaneous injection of sclerosant agents may be considered as a first-line treatment for LM and salivary epithelial duct cysts.

Ethanol Ablation of Ranulas and Risk Factor Analysis for Recurrence

Importance

Ethanol ablation (EA) was shown to be safe and effective for treating ranula, but few studies have assessed long-term outcomes and recurrence of ranula after EA.

Objective

To evaluate the long-term outcomes and the risk factors for recurrence and receipt of subsequent surgery in patients who underwent treatment with EA for ranula.

Design, Setting, and Participants

This case-series study was conducted at a single tertiary hospital and assessed patients who were treated with EA between July 2009 and March 2021. Among 70 consecutive patients, those with follow-up loss or who were followed up for less than 24 months were excluded.

Exposures

EA for ranula.

Main Outcomes and Measures

The primary outcome was recurrence at last follow-up after single or multiple EA sessions. Secondary outcomes included receipt of subsequent surgery and the recurrence-free survival (RFS) rate after initial EA. Factors possibly associated with outcomes included patient age and sex; ranula site, type, diameter, volume, and echogenicity; the presentation-to-EA interval; parapharyngeal space extension; and sublingual gland herniation. Risk factors were identified on logistic regression analyses. Two-year RFS rates were analyzed for the initial cohort using the Kaplan-Meier method and compared by log-rank tests.

Results

A total of 57 patients (mean [SD] age, 26.4 [12.1] years; 24 female individuals [42%]) who were followed up for a median of 57 months (range, 24-167 months) were included. The recurrence rate was 33% (n = 19), and 11 (19%) underwent subsequent surgery. Among patients with recurrence, 86% (31 of 36) experienced first recurrence within 12 months after initial EA. A presentation-to-EA interval of 12 months or longer was associated with an increased risk of recurrence (adjusted odds ratio [OR], 3.74; 95% CI, 1.01-13.82). No risk factors were significantly associated with subsequent surgery (highest OR in parapharyngeal space extension: adjusted OR, 4.96; 95% CI, 0.94-26.35). Among the initial cohort of 70 patients, 2-year RFS was lower in a maximum diameter of ranula of 5 cm or greater than less than 5 cm (24% [95% CI, 7%-41%] vs 50% [95% CI, 34%-66%]; difference, 26% [95% CI, -4% to 56%]; log-rank test, P = .02).

Conclusions and Relevance

This case-series study found that the recurrence rate of ranula after EA was 33%. A presentation-to-EA interval of 12 months or longer may be a risk factor for recurrence, suggesting that early intervention with EA might minimize recurrence. Most first recurrences occurred within 12 months after EA, with a maximum diameter of ranula of 5 cm or greater being a possible risk factor.

Ultrasound-Guided Ethanol Ablation for Thyroglossal Duct Cyst: A Review of Technical Issues and Potential as a New Standard Treatment

The thyroglossal duct cyst (TGDC) is the most common congenital neck mass, accounting for 70-75% of all congenital neck masses. Although the Sistrunk operation has been used as a standard of treatment, it is accompanied by a considerable surgical burden, including the need for general anesthesia, a visible surgical scar on the neck surface, and postoperative complications. Ultrasound-guided ethanol ablation (US-EA) is a minimally invasive and office-based technique that is widely used as a non-surgical treatment for several benign cystic lesions, particularly benign thyroid cysts. Recently, US-EA has also been gaining popularity as a good alternative for TGDC treatment, which is associated with high feasibility, a high safety profile, and favorable treatment outcomes. To our best knowledge, seven studies on the use of EA as a primary treatment option for TGDC have been published since 2011. Although these studies have reported promising results, there is a lack of consensus on several issues regarding the application of EA for TGDC, particularly its detailed techniques and role as a primary treatment. This article aims to provide a comprehensive review of EA for TGDC, addressing technical issues and its possible role as a new standard of treatment for TGDC.

The Use of Ethanol Sclerotherapy To Treat a Large Cervical Lymphocele

Cervical lymphoceles are atypical lymphatic accumulations that develop within the subcutaneous tissue of the neck. While these accumulations have traditionally been removed via surgical excision, sclerotherapy has recently emerged as a reasonable option to prevent injury to surrounding vascular, neurologic, and pulmonary structures. The purpose of this case report is to describe the efficacy of ethanol sclerotherapy for a cervical lymphocele refractory to surgical embolization. We present the case of a 70-year-old male with a large cervical lymphocele that was initially treated with surgical embolization. The mass rapidly reaccumulated within two weeks and the patient subsequently underwent ethanol sclerotherapy with no evidence of re-accumulation after 18 months. This case highlights the utility of ethanol due to its better side-effect profile, widespread availability, and cheaper cost when compared to better-described agents.

Ethanol ablation for the treatment of thyroglossal duct cysts: follow-up results for longer than 2 years

OBJECTIVES

To evaluate the long-term efficacy and safety of ethanol ablation (EA) for the treatment of thyroglossal duct cysts (TGDCs).

METHODS

This retrospective study included 81 consecutive patients diagnosed with and treated for symptomatic TGDCs at two institutions between Jan 2008 and Oct 2018. Preprocedural evaluation included US assessment with calculation of the TGDC volume. EA was performed under US guidance using 99% ethanol. Post-treatment follow-up was scheduled within 3 months, 6 months, and then annually. Immediate success was defined as a volume reduction ratio (VRR; ratio of the volume difference after EA to the initial TGDC volume) > 50% within 3 months. Long-term success was defined as VRR > 50% or resolution or improvement of cosmetic problems and symptoms without recurrence at last follow-up.

RESULTS

Seventy-seven patients underwent EA, and outcomes were assessed in 68 patients with available follow-up data. The immediate success rate of the first EA was 81% (55/68), with a mean VRR within 3 months of 73% ± 31%. One patient (1.5%, 1/68) developed wound inflammation after the first EA. Forty-two patients were followed up for longer than 2 years. For the median follow-up of 69 months (range, 24-131 months), the long-term success rate was 83% (35/42), with a mean VRR at last follow-up of 81% ± 35%. No patients developed malignancy from the ablated TGDCs.

CONCLUSIONS

EA for treatment of TGDCs achieved acceptable rates of immediate and long-term efficacy with a low complication rate, and can be considered as a first-line treatment for the management of TGDCs.

KEY POINTS

• The immediate success rate of EA for the treatment of TGDCs was 81% (55/68), with a mean VRR within 3 months of 73% ± 31%. • For the median follow-up of 69 months (range, 24-131 months), the long-term success rate was 83% (35/42), with a mean VRR at last follow-up of 81% ± 35%. • No patients developed malignancy from the ablated TGDCs but one patient (1.5%, 1/68) developed wound inflammation after the first EA.

Identification of a branchial cleft anomaly via handheld point-of-care ultrasound

Aim of the study

Branchial anomalies result from incomplete obliteration of the branchial arch structures during embryogenesis. Second branchial arch anomalies are commonly found on the lower third of the neck, with an opening at the anterior border of the sternocleidomastoid muscle, and may drain secretions or purulent material. This case demonstrates the use of handheld point-of-care ultrasound to aid in the diagnosis of a branchial anomaly.

Case description

The patient presented with a “hole” in the neck with intermittent drainage from the site. A 2 mm defect in the skin was noted anterior to the sternocleidomastoid muscle. A handheld ultrasound system was used to identify a well-defined, hypoechoic, cyst-like structure. Given the history, physical findings, and point-of-care ultrasound imaging, the diagnosis of a second branchial cleft sinus was made.

Conclusions

The use of point-of-care ultrasound and knowledge of the sonographic characteristics of these lesions can assist the physician in the diagnosis of branchial arch anomalies.

Efficacy of ethanol ablation as a treatment of benign head and neck cystic lesions

OBJECTIVE

To evaluate the efficacy and safety of ethanol ablation in the treatment of benign head and neck cystic lesions.

METHODS

A total of 25 patients who received ethanol ablation (EA) of head and neck cystic lesions by an otolaryngologist at a single institution between October 2017 and October 2020 were identified. Patient demographics, clinical characteristics, treatment details, and treatment outcomes at follow up visits were obtained by retrospective review of electronic medical records.

RESULTS

25 patients who underwent ethanol ablation of head and neck cystic lesions were included, with a mean age of 49.1 years old (Interquartile range (IQR),32.5-65.5 years) and 12 males (47.0%). The most common cysts treated with EA were thyroglossal duct cysts (n = 8, 32.0%) and lymphoepithelial parotid cysts (n = 7, 28.0%). The mean volume prior to treatment was 10.57 mL (IQR, 1.58-8.81 mL). Mean volume following EA was 1.30 mL (range, 0.10-0.97 mL) with 74.40% cyst reduction by volume (IQR, 48.56-96.29%) (p = 0.002). The mean time to the last follow-up was 5 months (range, 3-6 months). One patient received surgery despite treatment success to obtain a definitive diagnosis of the mass. No other patients received further surgical management. The treatment success of EA, as defined by >70% volume reduction or the resolution of symptoms, was 92.0%. All patients were satisfied with the outcome and had no reported complications.

CONCLUSION

EA is an effective and safe alternative to surgery for the treatment of head and neck cystic lesions that can be performed in an outpatient setting by an otolaryngologist.

Prenatal Diagnosis of Third and Fourth Branchial Apparatus Anomalies: Case Series and Comparison with Lymphatic Malformation

BACKGROUND AND PURPOSE

Third and fourth branchial apparatus anomalies are rare congenital anomalies. The purpose of this study was to investigate imaging features of these lesions on fetal MR imaging in comparison with lymphatic malformations, the major competing differential diagnosis in these cases.

MATERIALS AND METHODS

A retrospective review of our institutional fetal MR imaging database between 1997 and 2019 resulted in 4 patients with confirmed third and fourth branchial apparatus anomalies and 14 patients with confirmed lymphatic malformations. The imaging features were reviewed by consensus, and the Fisher exact test was used to evaluate statistically significant differences between these 2 populations.

RESULTS

Four cases of third and fourth branchial apparatus anomalies were imaged at 29 weeks 1 day (range, 23 weeks 1 day to 33 weeks 4 days). All 4 cases demonstrated unilateral, unilocular cysts without reduced diffusion or hemorrhage and a medially directed beaked contour that tapered between the spine and airway at the level of the piriform sinus. Compared with 14 cases of fetal lymphatic malformations imaged at 27 weeks 6 days (range, 21 weeks 3 days to 34 weeks 6 days), third and fourth branchial apparatus cysts were significantly more likely to be unilocular (P < .005) and to have a medially beaked contour (P < .005). The combination of features of unilateral, unilocular, and medially beaked contour was observed only in the fetuses with third and fourth branchial apparatus cysts (P < .001).

CONCLUSIONS

The presence of a left-sided unilocular cyst with a medially beaked contour tapering at the level of the piriform sinus suggests the diagnosis of third and fourth branchial apparatus anomaly. Accurate diagnosis in the prenatal period allows proper counseling, genetic work-up, and treatment, potentially sparing patients from recurrent infections and associated morbidity.

Chemical ablation using ethanol or OK-432 for the treatment of thyroglossal duct cysts: a systematic review and meta-analysis

OBJECTIVES

To review the effectiveness and safety of chemical ablation using ethanol or OK-432 for the treatment of TGDCs (thyroglossal duct cysts).

METHODS

MEDLINE and EMBASE databases were searched up to May 29, 2020, to identify studies reporting the safety and efficacy of chemical ablation using ethanol or OK-432 for the treatment of TGDCs. The search query consisted of synonyms of thyroglossal duct cysts and ethanol or OK-432 ablation. The pooled success and complication rates were calculated using the inverse variance method to calculate weights, and pooled proportions were determined using the DerSimonian-Laird random-effects method.

RESULTS

Seven original articles including a total of 129 patients were included. The efficacy of chemical ablation was acceptable, with a pooled success rate of 70% (95% CI, 47-86%). The pooled success rate of ethanol ablation was superior to that of OK-432 ablation, although with equivocal statistical significance (84% vs. 51%, p = 0.055). Repeat ethanol ablation achieved a pooled success rate of 47% (95% CI, 24-71%). The chemical ablation procedures were safe, with a pooled major complication rate of 0.9% (95% CI, 0.1-5.8%).

CONCLUSIONS

Chemical ablation using ethanol or OK-432 for the treatment of TGDCs had acceptable success and low complication rates, and repeat treatment after initial failure was also feasible. In addition, it is an inexpensive and simple procedure and could therefore be considered a first-line treatment for TGDCs.

KEY POINTS

• The efficacy of chemical ablation using ethanol or OK-432 was acceptable, with a pooled success rate of 70% (95% CI, 47-86%). The pooled success rate of ethanol ablation was superior to that of OK-432 ablation, although with equivocal statistical significance (84% vs. 51%, p = 0.055). • Repeat ethanol ablation was also feasible, with a pooled success rate of 47% (95% CI, 24-71%). • The chemical ablation procedures were safe, with a pooled major complication rate of 0.9% (95% CI, 0.1-5.8%).

Ultrasound-guided ethanol sclerotherapy for non-surgical treatment of Warthin's tumor

BACKGROUND

Currently, the first line treatment for Warthin's tumor (WT) is parotidectomy. There is a paucity of data evaluating the safety and efficacy of non-surgical treatments for patients not amenable to surgery. Ultrasound guided ethanol sclerotherapy (UGES) has been successfully used for the management of lymphangiomans of the head and neck, thyroid nodules, and thyroid cysts. This is the first study to implement and assess the success of UGES for management of WT.

METHODS

We report two patients with WT, with a total of 3 masses, who underwent UGES. All procedures were performed in the clinic. The primary outcome measured was the tumor volume reduction rate (VRR), patient satisfaction, and complications observed at follow-up.

RESULTS

Both patients experienced a significant reduction in tumor size upon follow up. VRR for the three treated tumors were 67.30%, 98.32%, and 55.73%. Patient were very satisfied with the results and noted significant cosmetic improvement. No complications were observed at follow-up.

CONCLUSIONS

Ultrasound guided ethanol sclerotherapy may be a viable option for conservative treatment of Warthin's tumor in patients unsuitable or unwilling to undergo surgical resection.

Feasibility of same day surgery for pediatric second branchial cleft anomalies

OBJECTIVE

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation.

METHODS

A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.

RESULTS

There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay.

CONCLUSION

Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

Ultrasound-guided-fine-needle Aspiration Drainage and Percutaneous Ethanol Injection for Benign Neck Cysts

Background:

Ultrasound-guided-fine-needle aspiration drainage (US-FNAD) and US-percutaneous ethanol injection (US-PEI) have been widely used in the management of benign neck cysts. However, the long-term results of US-FNAD and US-PEI are not well elucidated.

Methods:

We retrospectively collated patients under neck US examinations from March 2007 to December 2017 and investigated the recurrence after US-FNAD and US-PEI. Univariate and multivariate Cox regression analyses were used to assess significant risk factors for recurrence after US-FNAD.

Results:

A total of 1075 patients were recruited, and their age was 50 ± 15 (mean ± standard deviation) years. A total of 862 patients had thyroid cysts, 118 patients had thyroglossal duct cysts (TGDC), twenty patients had branchial cleft cysts, 64 patients had parotid sialocysts, and 11 patients had plunging ranulas. Majority of the patients (97%, 1037/1075) reported significant symptom improvement immediately. However, 38% of the patients had recurrence with a median 3-year follow-up period. In a multivariate Cox regression analysis with adjustment for age and gender, plunging ranula (hazard ratio [HR]: 2.44, 95% confidence interval [CI]: 1.19–4.99) and lateral dimension size ≥ 0.8 cm (HR: 1.32, 95% CI: 1.04–1.67) after US-FNAD were independent risk factors for recurrence. There were 15 male and 19 female patients who received US-PEI therapy after repeated US-FNAD, of whom 23 patients had thyroid cysts, 6 had plunging ranulas, 4 had TGDC, and one had a branchial cleft cyst. The overall success rate was 94% (32/34), with a median follow-up period of 1.6 years. Two recurrent symptomatic patients had plunging ranulas. Some patients stated mild pain (21%, 7/34) and swelling sensation (26%, 9/34) after the injection. No major complications, such as vocal fold paresis or airway compression, were found.

Conclusion:

US-FNAD is an effective tool in the management of benign neck cysts with a 38% recurrence rate. Plunging ranulas have the highest rate of recurrence after FNAD. US-PEI is effective for most recurrent neck cysts after repeated US-FNAD.