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Radiology Quiz Case 1: Diagnosis

Radiology Quiz Case 1: Diagnosis Diagnosis: Second branchial cleft fistula Branchial cleft anomalies, which result from incomplete obliteration of the branchial cleft in the embryological period, are occasionally seen in clinical practice. They may occur in any age group but are most common in the first 2 decades of life. Ninety-five percent of abnormalities of the branchial cleft apparatus arise from the second branchial cleft.1 Branchial cysts are more common (75% of branchial anomalies) than fistulas and sinuses. The clinical presentation of a branchial fistula is usually a continuous or intermittent discharging sinus in the front of the neck. Recurrent attacks of inflammation may follow an upper respiratory tract infection or mild trauma. Patients may also have deafness and other anomalies of the first and second branchial arch derivatives.2,3 On occasion, a cordlike structure that extends upward from the external orifice may be palpated. The anomalies are bilateral in 1% to 3% of cases. The branchial apparatus consists of a series of 6 mesodermal arches formed during early gestation that are externally separated by ectodermally lined branchial clefts and internally by endodermally lined pharyngeal pouches. The second arch increases in thickness and proliferates caudally to meet the enlarging ridge of the fifth arch; this causes the second, third, and fourth branchial clefts to become enclosed in a cavity, called the cervical sinus of His, which normally obliterates. Congenital abnormalities of the branchial apparatus can result in various abnormal conditions in the neck, including a cyst (a small, partial malformation with no external opening), a sinus (a malformation with one superficial opening), or a fistula (a complete malformation with both internal and external communications).4 The external skin opening is typically located along the anterior border of the junction of middle and lower thirds of the sternocleidomastoid muscle. The tract runs deep to the platysma muscles and ascends along the carotid sheath initially lateral to the common carotid artery but then courses medially between the external and internal carotid arteries. Next, it crosses above the hypoglossal and glossopharyngeal nerves and below the stylohyoid ligament to open finally into the tonsillar fossa.3 The epithelial lining of the fistula may be squamous or columnar in nature. The preoperative sinogram used in cases of branchial cleft anomalies is a painless, simple-to-perform, and effective method of confirming the diagnosis of a branchial cleft anomaly. The radiologic appearance of a smoothly marginated tract with an anatomical extent, as described above, is pathognomonic of a second branchial cleft anomaly,3 and no further investigations are required. The definitive treatment for branchial cleft fistulas is surgical excision. The sinogram helps to depict the exact anatomy and topography of these fistulas in the neck. Exact knowledge of the anatomical extent is required to prevent recurrence by incomplete surgical excision.5,6 Surgical dissection is often aided by the injection of methylene blue dye into the fistula or by the insertion of a thin catheter. Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters to the ARCHIVES commenting on cases presented. Quiz cases should follow the patterns established. See “Instructions for Authors.” Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be mailed to the Editor. Reprints are not available from the authors. References 1. Celis IBijnens EPeene PCleeren P The use of preoperative fistulography in patients with a second branchial cleft anomaly. Eur Radiol 1998;81179- 1180PubMedGoogle ScholarCrossref 2. Agaton-Bonilla FCGay-Escoda C Diagnosis and treatment of branchial cleft cysts and fistulae: a retrospective study of 183 patients. Int J Oral Maxillofac Surg 1996;25449- 452PubMedGoogle ScholarCrossref 3. Gold BM Second branchial cleft cyst and fistula. AJR Am J Roentgenol 1980;1341067- 1069PubMedGoogle ScholarCrossref 4. Shin LKGold BMZelman WHKatz DS Fluoroscopic diagnosis of a second branchial cleft fistula. AJR Am J Roentgenol 2003;181285PubMedGoogle ScholarCrossref 5. Ang AHPang KPTan LK Complete branchial cleft fistula: case report and review of literature. Ann Otol Rhinol Laryngol 2001;1101077- 1079PubMedGoogle Scholar 6. Herman TEMcAlister WHSiegel MJ Branchial fistula: CT manifestations. Pediatr Radiol 1992;22152- 153PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1: Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 131 (7) – Jul 1, 2005

Radiology Quiz Case 1: Diagnosis

Abstract

Diagnosis: Second branchial cleft fistula Branchial cleft anomalies, which result from incomplete obliteration of the branchial cleft in the embryological period, are occasionally seen in clinical practice. They may occur in any age group but are most common in the first 2 decades of life. Ninety-five percent of abnormalities of the branchial cleft apparatus arise from the second branchial cleft.1 Branchial cysts are more common (75% of branchial anomalies) than fistulas and sinuses. The...
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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.131.7.648
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Second branchial cleft fistula Branchial cleft anomalies, which result from incomplete obliteration of the branchial cleft in the embryological period, are occasionally seen in clinical practice. They may occur in any age group but are most common in the first 2 decades of life. Ninety-five percent of abnormalities of the branchial cleft apparatus arise from the second branchial cleft.1 Branchial cysts are more common (75% of branchial anomalies) than fistulas and sinuses. The clinical presentation of a branchial fistula is usually a continuous or intermittent discharging sinus in the front of the neck. Recurrent attacks of inflammation may follow an upper respiratory tract infection or mild trauma. Patients may also have deafness and other anomalies of the first and second branchial arch derivatives.2,3 On occasion, a cordlike structure that extends upward from the external orifice may be palpated. The anomalies are bilateral in 1% to 3% of cases. The branchial apparatus consists of a series of 6 mesodermal arches formed during early gestation that are externally separated by ectodermally lined branchial clefts and internally by endodermally lined pharyngeal pouches. The second arch increases in thickness and proliferates caudally to meet the enlarging ridge of the fifth arch; this causes the second, third, and fourth branchial clefts to become enclosed in a cavity, called the cervical sinus of His, which normally obliterates. Congenital abnormalities of the branchial apparatus can result in various abnormal conditions in the neck, including a cyst (a small, partial malformation with no external opening), a sinus (a malformation with one superficial opening), or a fistula (a complete malformation with both internal and external communications).4 The external skin opening is typically located along the anterior border of the junction of middle and lower thirds of the sternocleidomastoid muscle. The tract runs deep to the platysma muscles and ascends along the carotid sheath initially lateral to the common carotid artery but then courses medially between the external and internal carotid arteries. Next, it crosses above the hypoglossal and glossopharyngeal nerves and below the stylohyoid ligament to open finally into the tonsillar fossa.3 The epithelial lining of the fistula may be squamous or columnar in nature. The preoperative sinogram used in cases of branchial cleft anomalies is a painless, simple-to-perform, and effective method of confirming the diagnosis of a branchial cleft anomaly. The radiologic appearance of a smoothly marginated tract with an anatomical extent, as described above, is pathognomonic of a second branchial cleft anomaly,3 and no further investigations are required. The definitive treatment for branchial cleft fistulas is surgical excision. The sinogram helps to depict the exact anatomy and topography of these fistulas in the neck. Exact knowledge of the anatomical extent is required to prevent recurrence by incomplete surgical excision.5,6 Surgical dissection is often aided by the injection of methylene blue dye into the fistula or by the insertion of a thin catheter. Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters to the ARCHIVES commenting on cases presented. Quiz cases should follow the patterns established. See “Instructions for Authors.” Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be mailed to the Editor. Reprints are not available from the authors. References 1. Celis IBijnens EPeene PCleeren P The use of preoperative fistulography in patients with a second branchial cleft anomaly. Eur Radiol 1998;81179- 1180PubMedGoogle ScholarCrossref 2. Agaton-Bonilla FCGay-Escoda C Diagnosis and treatment of branchial cleft cysts and fistulae: a retrospective study of 183 patients. Int J Oral Maxillofac Surg 1996;25449- 452PubMedGoogle ScholarCrossref 3. Gold BM Second branchial cleft cyst and fistula. AJR Am J Roentgenol 1980;1341067- 1069PubMedGoogle ScholarCrossref 4. Shin LKGold BMZelman WHKatz DS Fluoroscopic diagnosis of a second branchial cleft fistula. AJR Am J Roentgenol 2003;181285PubMedGoogle ScholarCrossref 5. Ang AHPang KPTan LK Complete branchial cleft fistula: case report and review of literature. Ann Otol Rhinol Laryngol 2001;1101077- 1079PubMedGoogle Scholar 6. Herman TEMcAlister WHSiegel MJ Branchial fistula: CT manifestations. Pediatr Radiol 1992;22152- 153PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Jul 1, 2005

Keywords: radiology specialty

References

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