Embryology of Pharyngeal arches and it's clinical aspect.ppt
1. Embryology of Pharyngeal arches, Pouches,
Clefts: Correlation with common
developmental anomalies in ENT-Head & Neck
Dr. Kripa Dongol
M.S. (ORL-HNS) , 3rd Year Resident
GMSM Academy of ENT and HN Studies
TUTH, IOM
2. ROADMAP
• Development of pharyngeal arches, pouches & clefts
• Derivatives of pharyngeal arches, pouches & clefts
• Anomalies of pharyngeal arches
• Anomalies of pharyngeal clefts
• Anomalies of pharyngeal pouches
3. Pharyngeal Arches
• Typical feature in head and neck
• Develop - early 4th wk
• Neural crest cells migrate into the head and neck region
• Neural crest cell – skeletal components
4. Pharyngeal Arches
• 1st pair arches - surface elevations lateral to pharynx
• Other arches - rounded ridges on each side of the future
head and neck regions
5. Pharyngeal Arches
• Morphologically, they resemble gills in fish
• True gills (branchia) not formed so the term pharyngeal
arches is used in humans.
• Branchial - Greek word branchia or gill
• Formation of the face, ear and neck
6. Pharyngeal Arches
• End of the 4th wk - four pairs of pharyngeal arches visible
externally
• Arches separated from each other by fissures - pharyngeal
grooves
• Numbered in craniocaudal sequence
9. Pharyngeal Arches
• 1st (mandibular arch) - maxillary and mandibular prominences
• 1st pair - major role in facial development
• Maxillary process - premaxilla, maxilla, zygomatic bone, and
part of the temporal bone through membranous ossification
• 2nd arch (hyoid arch) - hyoid bone
10. Fate of Pharyngeal Arches
• 5th wk - 2nd pharyngeal arch enlarges and overgrows the 3rd &
4th arches, forms cervical sinus
• End of 7th wk - second to fourth pharyngeal grooves and the
cervical sinus have disappeared
11. Pharyngeal Arch Components
• Each arch contains
– Cartilage
– Cranial nerve
– Artery
– Muscle component
• All neural crest origin
• 6 arches, only 5 form
structures in humans
– 1, 2, 3, 4, and 6
– 5th fails to develop
12. Arch and nerve arrangement
Arch Post-trematic nerve Pre-trematic nerve
1st Mandibular nerve (V) Chorda tympani
branch of VII
2nd Facial nerve (VII) Tympanic branch of IX
3rd Glossopharyngeal (IX) -
4th&6th Superior and
Recurrent laryngeal
nerve
-
22. Pouches
• 4th Pouch
– Superior parathyroid glands
– Parafollicular C-cells of thyroid gland
• 5th Pouch
– Contributes to Ultimobranchial bodies (Parafollicular C-
cells)
23.
24. Migration of parathyroids & thymus
• Thymus - migrates in a caudal and a medial direction, pulling
the inferior parathyroid with it
• Increased proportion of anomalies of position of the inferior
parathyroid gland.
• Migration is complete at the end of the 7th week.
25.
26. Migration of parathyroids & thymus
• Superior parathyroid gland – usually above the inferior
thyroid artery and behind the recurrent laryngeal nerve
• Inferior gland - usually below the inferior thyroid artery
and in front of recurrent laryngeal nerve.
27. Pharyngeal Clefts
• Dorsal portion of 1st cleft – EAM (separated from the first
pouch by the tympanic membrane)
• 3rd month – meatal plug, 7th month – dissolve – if persist :
EAC atresia
• Second arch overgrows the second, third and fourth clefts,
forming the cervical sinus which then resorbs
28. Development of external ear
• 6 mesenchymal proliferations at the dorsal ends of the 1st
and 2nd pharyngeal arches, surrounding the first
pharyngeal cleft
• These swellings (auricular hillocks), three on each
side of the external meatus, later fuse and form the
definitive auricle
29. Development of external ear
• Hillock 1- anterior portion of the ear lobe, hillock 2 - tragus
and hillock 3 - ascending helix.
• Of the second arch hillocks, 4 and 5 produce the anti-helix
and the helix, with 6 - posterior lobule.
• Incomplete fusion of the hillocks - clefts and hypergenesis -
tubercles, tags and polyotia
Anotia Microtia
31. Development of tongue
Ant. 2/3 2 lingual & midline tubercular impar
Post. 1/3 3rd pharyngeal arch
Post. Most 4th arch
Muscles occipital somites
General sensation ant. 2/3 lingual n of V3
Taste frm ant. 2/3 corda tympani of VII
General n taste frm post. 1/3 CN IX
Post.most CNX
32. • Thyroid enlage behind tubercular impar- floor of the pharynx
and develops caudally.
• It enlarges and becomes bilobed at end of 7th week.
• The tract usually atrophies, caudal end remains as a pyramidal
lobe.
• Failure of the tract to involute - thyroglossal cyst
• The hyoid bone, developing later, may entrap a portion of the
thyroid duct or draw it caudally, leaving the duct dorsal to the
bone
33.
34. Branchial anomalies
• Result from improper development of the branchial
apparatus (Cyst, sinus or fistula)
• Cyst – Part of branchial groove or pouch become separated
from the surface and fails to resorb
• Sinus - Branchial groove or pouch fails to resorb & remains
open onto its epithelial surface
• Fistula – Passes from skin externally to pharynx or larynx
internally
35. Branchial anomalies
• A persistent cleft - external sinus, a blind ending opening onto
the skin.
• A persistent pouch will cause an internal sinus
• Persistence of both cleft and pouch will cause a fistula with an
internal and external opening
36. 1st Arch Anomalies
• Involves malformations of eyes, ears, palate and mandible
• 3 main manifestations of “First Arch Syndrome”
– Treacher Collins Syndrome
– Pierre Robin Syndrome
– Goldenhar Syndrome
37. Treacher Collins Syndrome
• Mandibulofacial dysostosis
• Inherited AD
• Features
– Midface, zygomatic and mandibular hypoplasia
– Ear anomalies: microtia, anotia, stenotic or atresia of EAC,
malformation of malleus and incus (CHL)
– Eye anomalies: coloboma of lower lids, down-slanting
palpebral fissures
– Cleft palate (35%)
– Normal intelligence
40. Pierre Robin Syndrome
• Sequence of :
– Micrognathia (small mandible)
– Glossoptosis (posterior displacement/retraction of tongue)
Upper airway obstruction
– Cleft palate (U-shaped)
– Primary defect - poor growth of the mandible - posteriorly
placed tongue that fails to drop from between the palatal
shelves, preventing their fusion
42. Pierre Robin Syndrome
Otolaryngological Considerations
• Airway compromise
– Upper airway obstruction
– Feeding, aspiration
• Hearing loss
– Otitis media most common
(60%)
Associated syndromes
Stickler (18-25%)
Velocardiofacial (7-15%)
Treacher Collins (5%)
Hemifacial microsomia (3%)
43. Goldenhar Syndrome
Oculoauriculovertebral Dysplasia
• No single genetic locus
• Disturbed neural crest cells at 30-45 days gestation
• First and second branchial arch
• Hemifacial microsomia when no internal organ
or vertebral disruption
48. 2nd Arch Anomalies
• Malformed auricle
– Microtia
• Ossicular malformation
– Stapes
– CHL
• Muscular asymmetry of face
• Hyoid malformation
– lesser horn and upper body
49. 3rd Arch Anomalies
• Hyoid anomalies
– Lower body
– Greater horn
• Aneurysm of carotid artery
50. 4th Arch Anomalies
• Laryngeal stenosis
• Laryngoptosis (low position of larynx)
• Chondromalacia
• Double aortic arch
• Pulmonary artery sling
– Left pulmonary artery originates from right pulmonary
artery
– Slings around right main-stem bronchus
51. First Branchial Cleft Anomalies
• Preauricular sinuses, cysts , Collaural fistula, EAC atresia
or stenosis
52. First Branchial Cleft Anomalies
• Periauricular sinuses and cysts
- Usually preauricular sinus with opening just infront of
ascending limb of helix
- Asymptomatic, infection
- Excision of cyst / sinus with tract (caution – facial nerve)
53. Collaural fistula
• < 5 % of branchial cleft anomalies
• Failure of resorption of ventral part of 1st branchial cleft
• Fistula runs from EAC or tragal notch to neck between
angle of mandible and sternocleidomastoid muscle
• In some cases, a skin-covered band runs from the floor of
the meatus to the umbo
• Track – starts from below auricle between angle of mandible
and sternocleidomastoid muscle through parotid
(medial/lateral or through facial nerve) opens into EAC
54. 1st Branchial Cleft Cyst
• Work Classification
– Type I
• Preauricular mass or sinus
• Ectoderm
• Sinus tract is anterior and medial to the EAC
– Preauricular region Lateral to CN VII Parallels EAC
Ends in EAC or middle ear
– Type II
• More common than Type I
• Ectoderm & Mesoderm
• Presents at the angle of mandible or submandibular region
– Angle of mandible Lateral or medial to CN VII Ends
in concha or bony-cartilaginous junction of EAC.
55. Collaural fistula
Presentation
• Discharge of epithelial or
sebaceous debris from opening
/ infection
Investigation
• Radioopaque sinogram using
water-soluble contrast will
demonstrate the extent of the
track
• MRI
Surgical excision - superficial
parotidectomy
56. Second Branchial Cleft Cysts
• Most Common (90%) branchial anomaly
• Failure of the cervical sinus to close may potentially
communicate with different branchial pouch
• Branchiooto-renal syndrome
• Congenital opening on the lower neck, anterior to
sternomastoid
57. Second Branchial Cleft Cysts
• Upper 2/3 & lower 1/3rd junction of SCM, deep to platysma,
lateral to IX, X, XII, between the internal and external
carotid and terminate in the tonsillar fossa
• Discharge / Infection
• Contrast sinogram to delineate track
• Surgical excision – step ladder incision
58.
59.
60. Third Branchial Cleft Cysts
• Rare (<2%)
• Similar external presentation to 2nd BCC
• Internal opening is at the pyriform sinus, then courses
cephalad to the superior laryngeal nerve through the
thyrohyoid membrane, medial to IX, lateral to X, XII,
deep/posterior to internal carotid
• Appearance - acute suppurative thyroiditis
• Left side
• Diagnostic delay
• Treatment - Endoscopy of the piriform fossa and
complete excision of the track
61.
62. 4th Branchial Cleft Cyst
• Very rare
– ~ 200 cases reported in the literature
• Also associated with recurrent thyroid abscesses
• Theoretical path of tract:
– Low in neck (anterior to SCM) , Deep to common carotid
Loops around aortic arch on the left (subclavian on
the right) lateral/superficial to CN IX Deep to
superior laryngeal nerve Superficial to recurrent
laryngeal nerve Opens into lower pharynx/pyriform
sinus
• Removal of a fourth branchial arch fistula - include excision
of the thyroid tissue to remove the whole tract
64. Work-up
• Ultrasound
• Round mass with uniform low echogenicity and lack of internal
septations
• Advantages: No radiation, no sedation for children, low cost
• CT
• Homogeneous lesion with low attenuation centrally and a
smooth enhancing rim
• Often part of the work-up
• More radiation, higher cost, may require sedation (children)
65. Work-up
• MRI
– Hypointense on T1 and hyperintense on T2
– Advantages: No radiation
– Disadvantages: Sedation for children, very expensive
• Fluroscopic fistulography or CT fistulography
– Inject radiopaque dye into the fistula or sinus to delineate course
• Barium swallow esophagography
– Help locate fistula tract in type 3 and 4 anomalies
• FNA
66. Treatment – Infected Cyst
• Antibiotics
– Should cover respiratory flora and Staph aureus (broad
spectrum)
– Cover 2-4 weeks
• Abscess
– Consider needle aspiration to drain
• May work without causing as much scaring as I&D
– I&D if needle aspiration doesn’t work
• Once infection cleared, operate
67. Treatment - Surgical
• Complete surgical excision of tract and cyst
• 1st cysts
– Must identify facial nerve as tract is usually
associated with it
– If possible, wait till 2 years of age
• Mastoid tip defined
• Facial nerve larger and deeper
• Controversy: waiting can lead to more infections more
scar more difficult surgery
– Lacrimal probes can help locate tract
68. Second Branchial Cleft Anomaly
Treatment
Surgery
Complete surgical excision of cyst and tract
Elliptical cervical incision
» Encompassing external sinus opening
Second ‘step-laddered’ incision
» Sinus excision
» Better exposure to pharynx
Methylene Blue
» Injected externally into the sinus tract
Lacrimal probe
» Fistula excision
69. Treatment - Surgical
• 3rd and 4th cysts
– Must identify the recurrent laryngeal nerve as closely
associated (will be deep to tract)
– Removal of ipsilateral thyroid lobe is advocated to
ensure complete removal of tract
– Perform DL to examine pyriform sinus
70. Endoscopic Cauterization of Pyriform Sinus
Opening
• Literature describes this for treatment of 4th sinus tracts,
but has been performed with 3rd cleft anomalies
• Recommendation
– Performed alone
– Performed with surgical resection of cyst and tract
71. Endoscopic Cauterization of Pyriform Sinus
Opening
• Verret et al.,2004
– Performed endoscopic cauterization of sinus in 10
children with 4th branchial cleft anomalies (no
surgical excision!)
• Dilated sinus opening with balloon catheter
cautery with electrocautery ball coagulator
• 7 showed no recurrent disease after 3 years
• 3 lost to F/U
73. 2nd Pouch Anomalies
• Thyroglossal duct cyst
– Failure of ablation of TGD
– Most common congenital neck mass
– Anywhere from base of tongue to upper mediastinum
– Typical finding
• Cystic lesion at or just below hyoid in midline that
moves with swallowing and tongue protrusion
– Sites
– Base of tongue
– Intralingual
– Suprahyoid
– Infrahyoid most common
-Prethyroid
-pretracheal
74. Thyroglossal Duct Cyst
– May contain thyroid tissue
• Potentially the only functioning thyroid
– Perform U/S or CT to look for thyroid and to assess lesion
– Treatment – surgical
– Excision : 85% recurrence vs Sistrunk’s : 2-8 %
– Modified Sistrunk’s operation
– May contain cancer
• 1%
• Papillary carcinoma
76. 2nd Pouch Anomalies
• Lingual Thyroid
– Failure of decent of thyroid -> atopic
• 90% of cases at the base of tongue (lingual thyroid)
– 4:1 female:male
– Usually not noted until teenage or young adult
– Asymptomatic (most cases); dysphagia, airway
compromise
– Reddish mass (well vascularized) at base of tongue
77. Lingual Thyroid
– Hypothyroidism – 70% of cases
– 2/3 cases – only functioning thyroid tissue
• Thyroid function study prior to treatment
– Treatment
• Asymptomatic – Monitor
• Symptomatic
– Excise +/- transplant tissue into muscles of neck
– Radioiodine therapy (destroys all thyroid tissue)
• Usually require lifelong thyroid replacement
80. Lateral cervical (or branchial) cysts
• Theories of aetiology –
a) Branchial apparatus theory – Remains of branchial
pouches or clefts. Later age at presentation.
b) Cervical sinus theory
c) Thymopharyngeal duct theory – Remnants of connection
between thymus and 3rd branchial pouch. But no persistent
thymic duct found.
d) Inclusion theory – (most accepted) Epithelial inclusions
within lymph node. Lymphatic tissue in wall of cyst,
Reported – Parotid, pharynx. Constant position of cyst in
neck (against)
TIBC
81. Lateral cervical (or branchial) cysts
Cl / f :
• Anterior to the upper 1/3 of
sternocleidomastoid in young
adults.
• Persistent or Intermittent swelling
• Cystic or firm
• 40% cases – URTI preceed
• Infection
Investigations
- USG neck, FNAC, CT scan neck
Plain radiographs reveal the malar hypoplasia, “tear drop”– shaped orbits and partial or complete absence of the zygomatic arches. In severe cases, there is absence of the lateral wall and the floor of the orbits (i.e., a clefting of the inferolateral orbit extending into the spheno-maxillary [inferior orbital] fissure).
Micrognathia: small mandible; Retrognathia: posterior displacement of mandible
Macroglossia and ankloglossia uncommon (10-15%)
CNS defects include: speech delay,epilepsy, neurodevelopmental delay, hypotonia, hydrocephalus
Upper airway obstruction includes obstructive sleep apnea.
Cleft palate hampers feeding/nursing and requires a special bottle (with a hole on top to allow effortless delivery of milk) or Haberman Feeder.
No mandibular “catch up” if other associated syndromes (i.e. Treacher Collins, Stickler). Catch-up is not complete in isolated cases.
The proportion of cases that are isolated Robin sequence varies in different studies. Hanson and Smith found that 25% of Robin sequence cases had specific syndromes, another 35% had multiple anomalies without a specific recognized syndrome, and only 40% had isolated Robin sequence. Another study found that 74% of cases were isolated Robin sequence.
Cummings: 80% associated with other syndromes.
Present in 1-2% of families, suggestive of an autosomal dominant familial pattern in some.
Lower eyelid coloboma in Treacher Collins
Parotid is often affected (agenesis or displaced)
Mental retardation in 5-15%
Congenital heart defects in 5-58%
Mandibular hypoplasia via hypoplasia or rami and condyles