Congenital cysts and sinuses of the neck develop from branchial arches and pouches during weeks 4-5 of gestation. The majority are second arch anomalies that present as a cyst or fistula on the lower anterior border of the sternocleidomastoid muscle in the first decade of life. Complete surgical excision is generally recommended after 3 months of age to prevent recurrence or infection, though antibiotics and aspiration may be used first if infection is present. The tract of a branchial fistula passes through the carotid bifurcation and structures derived from the second and third pharyngeal arches.

1. CONGENITAL CYSTS &CONGENITAL CYSTS &
SINUSES OF THE NECKSINUSES OF THE NECK

2. Development . . . .Development . . . .
 Head & neck is formed predominantly byHead & neck is formed predominantly by
bars of mesenchyme adjacent to mostbars of mesenchyme adjacent to most
cranial part of foregut.cranial part of foregut.
 Pharyngeal / Branchial arches.Pharyngeal / Branchial arches.
 Appear in the 4th & 5th week.Appear in the 4th & 5th week.
 There are potentially 6 Branchial arches.There are potentially 6 Branchial arches.

3.  Separated from the outside by deepSeparated from the outside by deep
clefts called branchial clefts.clefts called branchial clefts.
 Outpouchings occur in the lateralOutpouchings occur in the lateral
wall of the pharynx called branchialwall of the pharynx called branchial
pouches.pouches.
 Clefts meet corresponding pouch atClefts meet corresponding pouch at
the closing membrane.the closing membrane.
 Open communication in amphibiansOpen communication in amphibians
to form gills ( Branchia = gills ).to form gills ( Branchia = gills ).

4.  Each arch consists of a core ofEach arch consists of a core of
mesenchymal tissue & neural crestmesenchymal tissue & neural crest
cellscells
 Each arch is characterized by its ownEach arch is characterized by its own
muscular component. Thesemuscular component. These
muscular components of each archmuscular components of each arch
have their own cranial nerve &have their own cranial nerve &
arterial supply.arterial supply.

6. First (Mandibular) archFirst (Mandibular) arch
 Maxillary process - premaxilla, maxilla,Maxillary process - premaxilla, maxilla,
zygomatic & temporal bone.zygomatic & temporal bone.
 Mandibular process - Meckel’s cartilage -Mandibular process - Meckel’s cartilage -
mandible, malleus & incus.mandible, malleus & incus.
 Musculature: muscles of mastication,antMusculature: muscles of mastication,ant
belly of Digastric, Mylohyoid, Tensorbelly of Digastric, Mylohyoid, Tensor
tympani & palatini.tympani & palatini.
 Nerve: mandibular branch of TrigeminalNerve: mandibular branch of Trigeminal
nerve.nerve.
 Artery: maxillary arteryArtery: maxillary artery

7. Second (Hyoid) archSecond (Hyoid) arch
 Skeletal : Stapes, Styloid process ofSkeletal : Stapes, Styloid process of
Temporal bone, Stylohyoid ligament,Temporal bone, Stylohyoid ligament,
lesser horn & upper part of body oflesser horn & upper part of body of
hyoid.hyoid.
 Muscles - Stapedius, Stylohyoid,Muscles - Stapedius, Stylohyoid,
posterior belly of Digastric, Auricular,posterior belly of Digastric, Auricular,
muscles of facial expression.muscles of facial expression.
 Nerve – Facial nerve.Nerve – Facial nerve.
 Artery – Stapedial artery.Artery – Stapedial artery.

8.  3rd arch:3rd arch:
Skeletal: lower part of body & greaterSkeletal: lower part of body & greater
horn of hyoid.horn of hyoid.
Muscle: Stylopharyngeus.Muscle: Stylopharyngeus.
Nerve: Glossopharyngeal.Nerve: Glossopharyngeal.
Artery: Common carotid bifurcation,Artery: Common carotid bifurcation,
proximal internal carotid.proximal internal carotid.
 4th & 6th arches4th & 6th arches
Skeletal: Thyroid, Cricoid, Arytenoids,Skeletal: Thyroid, Cricoid, Arytenoids,
Corniculate & Cuneiform cartilages.Corniculate & Cuneiform cartilages.

9. Muscles :Muscles :
4th – Cricothyroid, Levator palitini &4th – Cricothyroid, Levator palitini &
constrictors of pharynx.constrictors of pharynx.
6th – intrinsic muscles of the larynx.6th – intrinsic muscles of the larynx.
Nerve:Nerve:
4th – superior laryngeal branch of4th – superior laryngeal branch of
the Vagus.the Vagus.
6th– recurrent laryngeal branch of6th– recurrent laryngeal branch of
Vagus.Vagus.

11. POUCHESPOUCHES
 1st – Tubotympanic recess.1st – Tubotympanic recess.
 2nd – Palatine tonsil. Part of pouch2nd – Palatine tonsil. Part of pouch
remains as tonsillar fossaremains as tonsillar fossa
 3rd – Dorsal wing forms inferior3rd – Dorsal wing forms inferior
parathyroid & ventral forms thymus.parathyroid & ventral forms thymus.
 4th – Superior parathyroid gland.4th – Superior parathyroid gland.
 5th – Ultimobranchial body5th – Ultimobranchial body

13. CLEFTSCLEFTS
 Dorsal part of 1st cleft formsDorsal part of 1st cleft forms
external auditory meatus.external auditory meatus.
 Mesenchyme of 2nd arch activelyMesenchyme of 2nd arch actively
proliferates to overlap 3 & 4th archesproliferates to overlap 3 & 4th arches
to merge with the epicardial ridge into merge with the epicardial ridge in
the lower part of the neck.the lower part of the neck.
This forms a cavity lined byThis forms a cavity lined by
ectodermal epithelium – cervicalectodermal epithelium – cervical
sinus – which eventually disappears.sinus – which eventually disappears.

15. THYROIDTHYROID
 Epithelial proliferation in the floor of theEpithelial proliferation in the floor of the
pharynx between the Tuberculum imparpharynx between the Tuberculum impar
& Copula indicated by foramen Caecum.& Copula indicated by foramen Caecum.
 Descends in front of the pharynx as aDescends in front of the pharynx as a
bilobed diverticulum.bilobed diverticulum.
 During this migration it remainsDuring this migration it remains
connected to the tongue by a narrowconnected to the tongue by a narrow
canal – Thyroglossal duct.canal – Thyroglossal duct.

16.  Thyroid descends in front of theThyroid descends in front of the
hyoid & laryngeal cartilages.hyoid & laryngeal cartilages.
 Reaches its final position in front ofReaches its final position in front of
trachea by 7th wk. It acquires atrachea by 7th wk. It acquires a
small median isthmus & two lateralsmall median isthmus & two lateral
lobes.lobes.
 Starts functioning by 4th month.Starts functioning by 4th month.

17. Branchial anomaliesBranchial anomalies
 More than 90% of branchial cleftMore than 90% of branchial cleft
anomalies are second arch anomaliesanomalies are second arch anomalies
 M:F equalM:F equal
 When sinus is present most BranchialWhen sinus is present most Branchial
anomalies are diagnosed in the firstanomalies are diagnosed in the first
decade of life, when there is nodecade of life, when there is no
external sinus diagnosis may not beexternal sinus diagnosis may not be
made until adulthoodmade until adulthood

18. Branchial CystBranchial Cyst
 Cyst presents as a soft mass deep toCyst presents as a soft mass deep to
the Sternomastoid muscle on itsthe Sternomastoid muscle on its
upper third.upper third.
 Sudden appearance of a painful massSudden appearance of a painful mass
in this location may be the first sign.in this location may be the first sign.
 Cysts usually between 5 – 10 cms inCysts usually between 5 – 10 cms in
size.size.

19.  Protrudes from beneath the anteriorProtrudes from beneath the anterior
border of sternomastoid.border of sternomastoid.
 Round to oval with long axis runningRound to oval with long axis running
forwards & downwards, cannot beforwards & downwards, cannot be
reduced or compressedreduced or compressed
 Usually not transilluminant.Usually not transilluminant.
 Branchiogenic carcinoma in 1%Branchiogenic carcinoma in 1%
remnants.remnants.

20. ManagementManagement
 Because of likelihood of infection excisionBecause of likelihood of infection excision
is generally recommended.is generally recommended.
 Complete excision to avoid recurrence.Complete excision to avoid recurrence.
 Surgery done after the age of 3 months.Surgery done after the age of 3 months.
 In presence of infection excision isIn presence of infection excision is
delayed. Antibiotics and needle aspirationdelayed. Antibiotics and needle aspiration
is advised.is advised.

21.  Incision is made parallel toIncision is made parallel to
Langers lines.Langers lines.
 Cyst may extend between theCyst may extend between the
origins of internal & externalorigins of internal & external
carotid arteries upto pharyngealcarotid arteries upto pharyngeal
wall.wall.
 Hypoglossal, GlossopharyngealHypoglossal, Glossopharyngeal
nerves lie deep to the cyst.nerves lie deep to the cyst.

22. Branchial FistulaBranchial Fistula
 Tiny pit in the skin at the lower third of antTiny pit in the skin at the lower third of ant
border of Sternomastoid muscle which mayborder of Sternomastoid muscle which may
discharge.discharge.
 Sinus b/l in 30% cases.Sinus b/l in 30% cases.
 Cord may be palpable running upward in theCord may be palpable running upward in the
neck from the ostium, milking the tractneck from the ostium, milking the tract
provides a mucoid discharge.provides a mucoid discharge.
 Swallowing will cause the fistula to be tuckedSwallowing will cause the fistula to be tucked
in causing prominent dimpling.in causing prominent dimpling.

23. Course of the fistulaCourse of the fistula
 From opening, passes subcutaneously toFrom opening, passes subcutaneously to
level of upper border of thyroid cartilage.level of upper border of thyroid cartilage.
 Pierces deep fascia & passes throughPierces deep fascia & passes through
bifurcation of common carotid.bifurcation of common carotid.
 All structures of second arch will beAll structures of second arch will be
superficial & 3rd arch will be deep.superficial & 3rd arch will be deep.
 It passes deep to post belly of digastric &It passes deep to post belly of digastric &
Stylohyoid.Stylohyoid.
 Superficial to IJV, Hypoglossal &Superficial to IJV, Hypoglossal &
Glossopharyngeal n & StylopharyngeusGlossopharyngeal n & Stylopharyngeus
muscle.muscle.
 Pierces superior constrictor & opens on thePierces superior constrictor & opens on the
posterior pillar of tonsillar fossa.posterior pillar of tonsillar fossa.

25. ManagementManagement
 Excision of the fistula.Excision of the fistula.
 Surgery done after the age of 3Surgery done after the age of 3
months.months.
 Placement of probe into the sinus.Placement of probe into the sinus.
 In a child Branchial fistula can beIn a child Branchial fistula can be
excised through a single incisionexcised through a single incision
incorporating the sinus opening,incorporating the sinus opening,
whereas in adolescents two stepladderwhereas in adolescents two stepladder
incisions may be required.incisions may be required.

26. Thyroglossal Duct Cyst:Thyroglossal Duct Cyst:
 Course of Thyroglossal duct:Course of Thyroglossal duct:
Down from foramen Caecum betweenDown from foramen Caecum between
the Genioglossi, then in midline either inthe Genioglossi, then in midline either in
front or through the hyoid, or hooksfront or through the hyoid, or hooks
below & behind the hyoid & thenbelow & behind the hyoid & then
descends downwards in the midline todescends downwards in the midline to
upper border of thyroid cartilage. Thenupper border of thyroid cartilage. Then
moves slightly to the left & ends inmoves slightly to the left & ends in
pyramidal lobe of thyroid.pyramidal lobe of thyroid.

27.  Most common congenital neck mass.Most common congenital neck mass.
 More than 50% diagnosed in first twoMore than 50% diagnosed in first two
decades of life.decades of life.
 A draining sinus is always the result ofA draining sinus is always the result of
spontaneous or surgical drainage.spontaneous or surgical drainage.
 60% are adjacent to hyoid, 24% above60% are adjacent to hyoid, 24% above
the hyoid, 13% below & 8%the hyoid, 13% below & 8%
intralingual.intralingual.

28.  Painless midline swelling, draining sinus or aPainless midline swelling, draining sinus or a
tender mass.tender mass.
 Occasionally may decompress into the mouthOccasionally may decompress into the mouth
producing bad taste.producing bad taste.
 Swelling moves with swallowing.Swelling moves with swallowing.
 Pulled up & fixed on protrusion of tongue.Pulled up & fixed on protrusion of tongue.
 Fluctuant, occasionally transilluminant.Fluctuant, occasionally transilluminant.
 Can be moved sideways but not vertically.Can be moved sideways but not vertically.

29.  Incidence of ectopic thyroidIncidence of ectopic thyroid
misdiagnosed as Thyroglossal cyst ismisdiagnosed as Thyroglossal cyst is
1 – 2%.1 – 2%.
 ? Thyroid scan to r/o Ectopic thyroid.? Thyroid scan to r/o Ectopic thyroid.
 If there are s/o hypothyroidism.If there are s/o hypothyroidism.
 USG of neck to demonstrate thyroidUSG of neck to demonstrate thyroid
at its normal site.at its normal site.

30. ManagementManagement
 Infected cyst – antibiotics & needleInfected cyst – antibiotics & needle
aspirationaspiration
 Incidence of malignancy – 1%Incidence of malignancy – 1%
 Excision of cyst along with completeExcision of cyst along with complete
thyroglossal tract upto the tongue,thyroglossal tract upto the tongue,
with excision of 0.5 cm of healthywith excision of 0.5 cm of healthy
tissue cuff around the tract.tissue cuff around the tract.
 May necessitate excision of segmentMay necessitate excision of segment
of hyoid in the midline. This is calledof hyoid in the midline. This is called
Sistrunk’s operationSistrunk’s operation

32. Thyroglossal FistulaThyroglossal Fistula
 Generally fistula appears off and on due toGenerally fistula appears off and on due to
recurrent infection & rupture of cystrecurrent infection & rupture of cyst
 Usually midlineUsually midline
 Hood or semi lunar fold of skin above theHood or semi lunar fold of skin above the
fistulafistula
 Excision – SistrunkExcision – Sistrunk
 Other cysts – Cystic Hygroma, DermoidOther cysts – Cystic Hygroma, Dermoid
cysts, Preauricular cysts & Thymic cystscysts, Preauricular cysts & Thymic cysts

33. Cystic HygromaCystic Hygroma
 Aggregation of cysts containing clearAggregation of cysts containing clear
lymphlymph
 Sites – Posterior triangle of neckSites – Posterior triangle of neck
Cheek, Axilla, Mediastinum,Cheek, Axilla, Mediastinum,
GroinGroin
 Earliest swelling seen in the neckEarliest swelling seen in the neck
 Lower third of neck in the posteiorLower third of neck in the posteior
triangletriangle

34.  Occasionally very large.Occasionally very large.
 Soft, cystic, smooth / lobulatedSoft, cystic, smooth / lobulated
surface, compressible.surface, compressible.
 Brilliant Transillumination.Brilliant Transillumination.
 May cause respiratory distressMay cause respiratory distress
 Infection.Infection.
 Complete excision in single or stagedComplete excision in single or staged
manner.manner.
 Monoclonal antibody – OK-432Monoclonal antibody – OK-432
extracted from Streptococcusextracted from Streptococcus
pyogenes.pyogenes.