BRANCHIAL CYST & BRANCHIAL FISTULAE

- 4 CASE REPORTS

KALARANJANI.V
II MBBS
IGMC&RI
 INTRODUCTION
 Branchial anomalies - 17% of paediatric cervical masses.
Male : female ratio- 3:2
 Branchial cleft anomalies - incomplete inutero reabsorption
of pharyngeal clefts and pouches.
 Branchial cysts and fistulae are common manifestations.
Branchial cyst develops from persistent cervical sinus
Congenital branchial fistula is a persistent second branchial
cleft with a communication outside to the exterior.
 MATERIALS & METHODS

4 cases were reported from the Department of Surgery, Indira

Gandhi Medical College & Research Institute, Pondicherry
during the year 2013, from January to July:

1. Unilateral right branchial cyst in a 6 year old female

2. Bilateral branchial fistula (second arch) in a 7 year old
female
3. Unilateral left branchial fistula (second arch) in a 11 year
old male
4. Unilateral left branchial fistula (third arch) in a 23 year old
female
 OBSERVATION

UNILATERAL RIGHT BRANCHIAL CYST

 ????? BILATERAL
BRANCHIAL FISTULA
UNILATERAL LEFT
BRANCHIAL FISTULA
UNILATERAL LEFT BRANCHIAL FISTULA (SECOND
ARCH)
IN A 11 YEAR OLD MALE
 SURGICAL
EXCISION OF THE TRACT

EXCISED TRACT
 PHARYNGEAL ARCHES:
The pharyngeal arches begin to develop early in the fourth week as neural crest
cells which migrate to the future head and neck region.
The first arch appears as surface elevation lateral to the pharynx. Soon other
arches appear as obliquely disposed rounded ridges on each side.
Along with the migration of neural crest cells, the myogenic mesoderm from
paraxial regions move into each pharyngeal arch and form the central core of
muscle primordium.
Endothelial cells derived from both the lateral mesoderm and angioblasts move
into the arches.
By the end of fourth week, four pairs of pharyngeal arches are visible externally.
Fifth and sixth arches are rudimentary .
A typical pharyngeal arch contains a pharyngeal arch artery, a cartilaginous rod ,
a muscular component and sensory & motor nerves supplying the mucosa and
muscles derived from the arch
 PHARYNGEAL pouches and grooves:

The pharyngeal arches are separated by pharyngeal clefts externally and

pharyngeal pouches internally.
There are four well defined pairs of pharyngeal pouches.
The endoderm of the pharyngeal arch contacts the ectoderm of pharyngeal arch
and together they form the pharyngeal membrane which separates the pharyngeal
pouches from the clefts.
Fate of the PHARYNGEAL ARCHES:

They are involved in the formation of face, nasal cavities, mouth, pharynx,
larynx and neck.
During the fifth week the second pharyngeal arch overgrows the third and fourth
arches and an ectodermal depression called cervical sinus is formed.
By the end of seventh week, second to fourth pharyngeal grooves disappears
giving the neck a smooth contour.
 BrANCHIAL cyst

Branchial cysts are vestigial remnants of second branchial cleft. It usually appears
at 35days of foetal life
It usually presents in the upper neck at the junction of upper and middle 1/3 of
anterior border of sternocleidomastoid.
It may also be foumd within the parotid gland, pharyngeal wall, manubrium and
mediastinum.
 It is lined by squamous epithelium and contains thick, turbid fluid full of
cholesterol crystals.
Fluctuation test is positive and transillumination is usually negative.
The cyst is superficial to hypoglossal and glossopharyngeal nerve and deep to
posterior belly of digastric
COMPLICATION
S:
Recurrent infection because of presence of lymphoid tissue in the wall. This is
followed by bursting resulting in formation of fistula.
When this is infected it looks like a hot abscess and when inadvertently incised br
fistula is formed.
DIFFERENTIAL DIAGNOSIS:

Cold abscess in the neck

Cervical dermoid
Plunging ranula
Cystic hygroma
Carotid body tumour
Solitary enlarged cervical lymph node
Submandibular salivary gland swelling

TREATMENT:

Cysts may be percutaneously drained and if unsuccessful maybe excised. Infected

cyst is aspirated first and then excised. Skin crease incision 2cm below the angle of
jaw is made to avoid injury to cervical branch of facial nerve.
Structures to be taken care of during excision are Carotid arteries, Hypoglossal
nerve, Glossopharyngeal nerve, Spinal accessory nerve, posterior belly of digastric
and pharyngeal wall and medially it is close to posterior pillar of tonsils.
 HISTOLOGY OF AXIAL CT SCAN SHOWING
PREAURICULAR FIRST RIGHT BRANCHIAL CLEFT
BRANCHIAL CLEFT CYST CYST
 BrANCHIAL fistula

It is a persistent second branchial cleft with a communication outside to the

exterior.
It is commonly a congenital fistula. Occasionaly the condition is secondary to
incised, infected branchial cyst.
External orifice is situated in the lower third of the neck near the anterior border of
sternocleidomastoid muscle.
Internal orifice is located on the anterior aspect of the posterior pillar of the fauces,
just behind the tonsils.
Tract is lined by ciliated columnar epithelium with patches of lym[phoid tissues
beneath it, causing recurrent inflammation.
Discharge is mucoid or mucopurulent.
Discharge study and fistulogram are the investigations usually done.
TREATMENT:
The treatment is usually surgery. Under general anaesthesia methylene blue is
injected into the track. Probe is passed into the fistulous track. Through
circumferential/ elliptical incision around the fistula opening, entire length of the
track is dissecyted until the internal orifice.