Head and Neck sinuses and masses

@ surgeons discretion

Etiology

Infection

Trauma

Neoplasm

Congenital

Benign

Malignant

Neuroblastoma

Lymphoma

Rhabdomyosarcoma

Embryonic origin

Congenital cysts and sinuses result from embryonic structures that failed to mature o persisted in an aberrant fashion

Cartilagenous remnants
Remnants of the branchial arch and cleft
Midline fusion abnormalities

Complete resection = avoids recurrence

Thryoglossal duct cyst
Preauricular pits and sinuses
Branchial cleft anomalies
Dermoid cysts
Median cervical clefts

Thyroglossal duct cyst

❗Most common lesion of the midline❗
Preschool children

Foramen cecum

Site of thyroid diverticulum development
Structure develops caudal to the central tuberculum impar (Pharingeal bud that leads to formation of the tongue)

Thyroid irrigation & drainage

Blood supply

Venous drainage

Innervation

Superior thyroid a. (paired) o. External carotid artery

Inferior thyroid a. (paired) o. Thyrocervical trunk --
o. subclavian artery
OR
o. subclavian artery 15% people

IMA o. Ao. Arch or innominate a.

Infrahyoid
Sternocleidomastoid
Superior laryngeal
Cricothyroid
Inferior pharyngeal constrictor
Terminal branches

High ligation of S.Thyroid artery -- may damage external branch SLN

plexus of vessels lying in the substance and on the surface of the gland

Superior thyroid vein
Middle thyroid vein
Inferior thyroid vein

R. brachiocephalic vein

L. brachiocephalic vein

Embryology:
Develops btw w. 4-7 weeks gestation

Appropriate position w. 5 (5-8)

Location: Anywhere along migratory course of thyroglossal tract if it fails to be obliterated

Failure of complete migration:
LINGUAL THYROID

Beneath the foramen cecum @ base of the tongue

Location:
60% Adjacent to hyoid bone
24% Suprahyoid
13% Infrahyoid
8% Intralingual

Presentation:
Painless mass in the midline

PE: Smooth, soft and non-tender
Palpate the lesion while child sticks out his/her tongue.

Cyst moves cephalad when tongue protrudes

Infection 1/3

Mouth flora

Draining sinus 1/4

Preop prep

TFT to r/o median ectopic thryoid 10-45%

Ectopic thyroid
90% located @

Excision of thyroglossal duct cyst

Avoid complications

Infection

Papillary thryoid carcinoma

Transverse incision
Dissect the cyst cephalad to hyoid bone
Base of the tract ligated with absorbable suture
Wide excision
No need to approximate hyoid

Anesthesiologist finger @ base of the tongue
2 identify cephalad extent of dissection

Surgery

Complications

Leave drain??

@ surgeons discretion

Treatment

Ethanol ablation

Sclerotherapy

Marsupialization

Excision

Surgical

Post OP

Enter floor of the mouth

Repair with absorbable suture

Major:

RECURRENCE 2-5%
Hematoma or abscess needing drainage
Entry into airway or traqueotomy
Hypoglossal nerve paralysis
Hypothryroidsm & death

Minor 29%:

Seroma formation
Wound dehiscence
Local wound infection
Stitch abscess

Recurrence RISK FACTORS

Simple cyst excision alone (38-70%)
Intraoperative cyst rupture
Presence of cutaneous component secondary to infection
Post op wound infection

+ INCISION AND DRAINGE (AVOID)

S. aureus
S. epidermidis
H. influenzae

Treat & wait 3 mo. before surgery

Passed through hyoid bone

Ganglion

Pretracheal ganglion
VI

Hemangiomas

Lymphangiomas

Cystic hygromas

Location:

Adjacent to hyoid 66%
Suprahyoid 24%
Infrahyoid 13%
8% Intralingual

<1%

Excision of infected cyst has a recurrence of 25%

If solid mass found

Exclude median ectopic thyroid

Remnants of embryonic Branchial apparatus

Cyst

Sinuses

Fistula

Persistence of the branchial groove c breakdown of the branchial membrane

Remnants of sinuses s external opening.

Appear later in childhood

Persistence of the eternal opening only

Congenital

Present at birth

End of fistula, # of syllables in the word

Ear

Tonsil

Pyriform

Presentation

Drainge along SCM

Diagnosis

MRI

Barium esophagogram

1st cleft anomalies

Mandible

Type I

Type II

Duplications of the membranous external auditory canal
Medial to the concha often extending into the postauricular crease and ending at the osseous- cartilagenous jct of the EAC

Squamous epithelium

Duplications of both the membranous and cartilagenous EAC c tract opening in the parotid gland and the neck below the angle of the mandible extending toward the inferior part of the EAC

Ectoderm

Lateral to the facial nerve

Swelling near the ear

Mesoderm and Ectoderm

Medial to the facial nerve

2nd cleft anomalies

2nd arch

2nd pouch

Tonsillar
Supratonsillar fossa

Hyoid bone
Superior body

3rd. cleft anomalies

4th cleft anomalies

Superior parathyroid
Ultimobranchial body

Inferior Parathyroid
Thymus

Ascends posterior to the carotid artery

Sinuses frequent on the R side

Bilateral 10% cases

Found in the L side
Lower portion of the anterior neck

Sx. BranquiOtoRenal

Mayor Criteria

MInor Criteria

Ear anomalies

Facial asymmetry

Preauricular pits

1st. study

Fistulogram

Squamous epithelium

3rd. and 4th

Tonsillectomy

Presentation

SCM
Anywhere along the SCM tract

Not recommended
Does not increase recurrance risk

Complications

+Salivary fistulas
+EAC stenosis
+Facial palsy
+Hearing loss

Complications

Recurrence 3-22%
Vocal chord paralysis
Hematoma
Seroma

Complications

Recurrence
Salivary fistulas

MR
Gammagram

Differential dx.

Dermoid cyst
Branchial arch cysts
Lipoma
Thyroid nodules
Pyramidal lobe hypertrophy
Midline adenopathy

Abx. Amox/Clav 10-14 d.
Clindamycin

Sistrunk

Recurrence 33-56%

Follow up

1 wk
1mo.
6mo.
Yearly

US Microcalcifications

Dx c path

Tx. Papillary thyroid carcinoma

Sistrunk+Thyroidectomy + ganglion resection

click to edit