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A wattle (cervical accessory tragus)
A wattle (cervical accessory tragus) EREZ BENDET, MD, Hadera, Israel
A wattle is a fleshy appendage occurring about the neck. The term is usually applied to dewlap of birds such as cocks and turkeys, but such skin tags occur also in pigs, sheep, and Egyptian goats. Clarke1 first applied the term to congenital cervical appendages that occur in human beings. CASE REPORT A 10-month-old boy had a congenital outgrowth in his left neck located at the anterior border of the sternocleidomastoid muscle (Fig. 1). There was no evidence of an associated pit, opening through the skin, or underlying cyst. He also had microtia and stenosis of the left external auditory canal. The cervical lesion was pedunculated, fleshy, and skin-colored, and the peduncle had a firm core. On excision, the lesion was found to have a firm core extending toward the platysma layer, and that was dissected. A small central artery that supplied the lesion was coagulated. The specimen measured 1 × 0.9 × 2.5 cm. Histologically, it was covered with skin that contained sweat glands in the subcutis. Underneath the dermis was adipose tissue. The peduncle contained a core of cartilage. The cartilage stained with van Gieson-elastica stain, revealing elastic fibers surrounding the individual cartilage cells. DISCUSSION Clarke1 was the first to coin and apply the term wattle to congenital cervical appendages that occur in human beings and have distinctive histologic features, notably a cartilaginous core. This anomaly is rare, occurring much less frequently than branchial cysts or sinuses. The male-to-female incidence ratio is reported to be 2:1.2 Wattles may rarely occur bilaterally and may be hereditary.2 In another family that I treated, wattles and accessory tragi occurred, sometimes concomitantly, through four generations with an autosomal dominant mode of inheritance. The embryonic origin of wattles is debated to be from either branchial arch remnants or ectopic auricular tissue.1 These theories are reflected by descriptions like branchial appendage, branchial remnant, or branchioma, versus cervical auricle, accessory auricle, or cervical accessory tragus.2 Proponents of the branchial remnant theory point to the cervical auricle, accessory auricle, or cervical accessory tragus.2 From Otolaryngology-HNS Unit, Hillel Yaffe Medical Center. Reprints not available from the author. Otolaryngol Head Neck Surg 1999;121:508-9. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/11/87071 508
Proponents of the branchial remnant theory point to the cervical location of wattles, their rare association with adjacent branchial sinuses, and the occasional occurrence of epithelial rests within the tag.1 Those who believe that they are of auricular cartilage origin point out that wattles, like the tragus, contain a core of elastic cartilage.1,3 During the fourth week of gestation, the auricle begins its development from the first (mandibular) and second (hyoid) branchial arches. Initially the primitive auricles are located in the lower lateral neck, but with the development of the mandible they ascend to the side of the head level with the eyes. During the fifth and sixth weeks the first and second arches form six mesenchymal tubercles, the hillocks of His. Which part of the auricle is derived from each hillock is controversial.4 One theory holds that each tubercle develops into a certain portion of the final auricle: the first to third hillocks, derived from the mandibular arch, develop into the tragus, crus of the helix, and the majority of the helix, respectively, whereas the fourth to sixth hyoid hillocks form the antihelix, antitragus, and the lower helix and lobule, respectively. Another theory, based on studies that showed that in the 18 mm embryo these hillocks are no longer visible, holds that they do not represent anlagen of specific portions of the auricle and that the mandibular arch gives origin to the tragus, whereas the remainder of the auricle, except the concha, originates from the hyoid arch.4 Thus both theories agree that the tragus is derived from the first arch. Brownstein et al.,5 reporting on 55 cases of accessory tragi, found 16 that occurred in the neck.5 It is conceivable that because of embryonic maldevelopment, remnants of tissue may be left along the line of migration of the auricle. I subscribe to the view of Sebben6 that wattles should be con-
Fig 1. A 10-month-old boy with congenital wattle.
Otolaryngology– Head and Neck Surgery Volume 121 Number 4
sidered the cervical version of accessory tragus. The association of microtia and stenosis of the external ear canal in the current case and its staining for elastic fibers in the cartilage further strengthen this view. The confusion in the literature regarding the origin and the correct nomenclature is caused by the difficulty in the clinical differential diagnosis of wattles that include mainly sentinel tags next to branchial sinuses or fistulas, skin tags (acrochordon), and benign papillomas. The appropriate diagnosis is often made only after pathologic examination. Histologically, wattles are distinctive because their skin appendages contain eccrine glands and pilosebaceous units. However, in children between a few months of age and puberty, the sebaceous glands are either very small or barely discernible.5 Most wattles have a core of elastic cartilage. Those regarding wattles as a branchial anomaly probably describe sentinel tags adjacent to branchial sinuses or fistulas that contain epithelial remnants and lymphoid tissue. Acrochordons have fibrovascular stroma
BENDET
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and do not contain skin appendages or cartilage. Papillomas have warty features. Excision is usually performed for cosmetic reasons. Remember that wattles may communicate with deeper structures, and simple shaving may leave the cartilage exposed with potential subsequent complications. REFERENCES 1. Clarke JA. Are wattles of auricular or branchial origin? Br J Plast Surg 1976;29:238-44. 2. Lindgren VV. Bilateral cartilaginous branchial remnants (branchial appendages). Plast Reconstr Surg 1956;17:304-8. 3. Christensen P, Barr RJ. Wattle: an unusual congenital anomaly. Arch Dermatol 1985;121:22-3. 4. Kenna MA. Embryology and developmental anatomy of the ear. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 77-8. 5. Brownstein MH, Wanger N, Helwig EB. Accessory tragi. Arch Dermatol 1971;104:625-31. 6. Sebben JE. The accessory tragus—no ordinary skin tag. J Dermatol Surg Oncol 1989;15:304-7.
A wattle is a fleshy appendage occurring about the neck. The term is usually applied to dewlap of birds such as cocks and turkeys, but such skin tags occur also in pigs, sheep, and Egyptian goats. Clarke1 first applied the term to congenital cervical appendages that occur in human beings. CASE REPORT A 10-month-old boy had a congenital outgrowth in his left neck located at the anterior border of the sternocleidomastoid muscle (Fig. 1). There was no evidence of an associated pit, opening through the skin, or underlying cyst. He also had microtia and stenosis of the left external auditory canal. The cervical lesion was pedunculated, fleshy, and skin-colored, and the peduncle had a firm core. On excision, the lesion was found to have a firm core extending toward the platysma layer, and that was dissected. A small central artery that supplied the lesion was coagulated. The specimen measured 1 × 0.9 × 2.5 cm. Histologically, it was covered with skin that contained sweat glands in the subcutis. Underneath the dermis was adipose tissue. The peduncle contained a core of cartilage. The cartilage stained with van Gieson-elastica stain, revealing elastic fibers surrounding the individual cartilage cells. DISCUSSION Clarke1 was the first to coin and apply the term wattle to congenital cervical appendages that occur in human beings and have distinctive histologic features, notably a cartilaginous core. This anomaly is rare, occurring much less frequently than branchial cysts or sinuses. The male-to-female incidence ratio is reported to be 2:1.2 Wattles may rarely occur bilaterally and may be hereditary.2 In another family that I treated, wattles and accessory tragi occurred, sometimes concomitantly, through four generations with an autosomal dominant mode of inheritance. The embryonic origin of wattles is debated to be from either branchial arch remnants or ectopic auricular tissue.1 These theories are reflected by descriptions like branchial appendage, branchial remnant, or branchioma, versus cervical auricle, accessory auricle, or cervical accessory tragus.2 Proponents of the branchial remnant theory point to the cervical auricle, accessory auricle, or cervical accessory tragus.2 From Otolaryngology-HNS Unit, Hillel Yaffe Medical Center. Reprints not available from the author. Otolaryngol Head Neck Surg 1999;121:508-9. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/11/87071 508
Proponents of the branchial remnant theory point to the cervical location of wattles, their rare association with adjacent branchial sinuses, and the occasional occurrence of epithelial rests within the tag.1 Those who believe that they are of auricular cartilage origin point out that wattles, like the tragus, contain a core of elastic cartilage.1,3 During the fourth week of gestation, the auricle begins its development from the first (mandibular) and second (hyoid) branchial arches. Initially the primitive auricles are located in the lower lateral neck, but with the development of the mandible they ascend to the side of the head level with the eyes. During the fifth and sixth weeks the first and second arches form six mesenchymal tubercles, the hillocks of His. Which part of the auricle is derived from each hillock is controversial.4 One theory holds that each tubercle develops into a certain portion of the final auricle: the first to third hillocks, derived from the mandibular arch, develop into the tragus, crus of the helix, and the majority of the helix, respectively, whereas the fourth to sixth hyoid hillocks form the antihelix, antitragus, and the lower helix and lobule, respectively. Another theory, based on studies that showed that in the 18 mm embryo these hillocks are no longer visible, holds that they do not represent anlagen of specific portions of the auricle and that the mandibular arch gives origin to the tragus, whereas the remainder of the auricle, except the concha, originates from the hyoid arch.4 Thus both theories agree that the tragus is derived from the first arch. Brownstein et al.,5 reporting on 55 cases of accessory tragi, found 16 that occurred in the neck.5 It is conceivable that because of embryonic maldevelopment, remnants of tissue may be left along the line of migration of the auricle. I subscribe to the view of Sebben6 that wattles should be con-
Fig 1. A 10-month-old boy with congenital wattle.
Otolaryngology– Head and Neck Surgery Volume 121 Number 4
sidered the cervical version of accessory tragus. The association of microtia and stenosis of the external ear canal in the current case and its staining for elastic fibers in the cartilage further strengthen this view. The confusion in the literature regarding the origin and the correct nomenclature is caused by the difficulty in the clinical differential diagnosis of wattles that include mainly sentinel tags next to branchial sinuses or fistulas, skin tags (acrochordon), and benign papillomas. The appropriate diagnosis is often made only after pathologic examination. Histologically, wattles are distinctive because their skin appendages contain eccrine glands and pilosebaceous units. However, in children between a few months of age and puberty, the sebaceous glands are either very small or barely discernible.5 Most wattles have a core of elastic cartilage. Those regarding wattles as a branchial anomaly probably describe sentinel tags adjacent to branchial sinuses or fistulas that contain epithelial remnants and lymphoid tissue. Acrochordons have fibrovascular stroma
BENDET
509
and do not contain skin appendages or cartilage. Papillomas have warty features. Excision is usually performed for cosmetic reasons. Remember that wattles may communicate with deeper structures, and simple shaving may leave the cartilage exposed with potential subsequent complications. REFERENCES 1. Clarke JA. Are wattles of auricular or branchial origin? Br J Plast Surg 1976;29:238-44. 2. Lindgren VV. Bilateral cartilaginous branchial remnants (branchial appendages). Plast Reconstr Surg 1956;17:304-8. 3. Christensen P, Barr RJ. Wattle: an unusual congenital anomaly. Arch Dermatol 1985;121:22-3. 4. Kenna MA. Embryology and developmental anatomy of the ear. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 77-8. 5. Brownstein MH, Wanger N, Helwig EB. Accessory tragi. Arch Dermatol 1971;104:625-31. 6. Sebben JE. The accessory tragus—no ordinary skin tag. J Dermatol Surg Oncol 1989;15:304-7.