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Branchial Cysts and Fistulas: Clinical Aspects and Treatment
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Branchial Cysts and Fistu!as Clinical Aspects and Treatlllent CORNELIUS E. SEDGWICK
THE embryologic origin and pathogenesis of branchial cysts and fistulas have been described by Dr. Hicks (page 619). The purpose of this paper is to present the clinical manifestations and therapy of these neck tumors. Recently, we* studied the clinical aspects and treatment of 75 cases of branchial cysts and fistulas seen at the Lahey Clinic. It is apparent from this study that there are significant differences in the history and objective findings in these two conditions and that relative to diagnosis and treatment it is easier to think of branchial cysts and branchial fistulas as two distinct entities. BRANCHIAL FISTULAS
Branchial fistulas occur equally in males and females. The fistula is usually seen at birth or shortly thereafter. It may occur on either side and is usually unilateral but may be bilateral. Branchial fistulas appear as small dimples or pinpoint sized openings in the lateral region of the neck (Fig. 144). The opening is usually in close association with the anterior border of the sternocleidomastoid muscle, most often in the lower third of the neck, although sometimes in the middle third or even the upper third of the neck. Occasionally, the patient will state that the sinus drains more when he has a cold or upper respiratory infection. The diagnosis is not difficult. The only other common draining lateral cervical sinus is secondary to tuberculous adenitis. We believe that branchial fistulas should be excised when discovered except in the very young or in the presence of active inflammation. The operation consists of excising the entire tract from the external skin opening up to the entrance of the fistulous tract into the pharyngeal wall. The type of incision depends somewhat upon the location of the external opening and the length of the sinus tract. If the opening, as is
* Sedgwick, C. E. and Walsh, J. F.: Branchial cysts and fistulas: A study of seventy-five cases relative to clinical aspects and treatment. Am. J. Surg. 83: 3-8 (Jan.) 1952. 627
Cornelius E. Sedgwick
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Fig. 144. Typical branchial fistula in a young boy. The fistula can be seen as a small dark area at the anterior border of the left sternocleidomastoid muscle in the lower third of the neck. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
FISTUL.DuS
TRACT
Fig. 145. Excision of branchial fistula. a, Lower transverse elliptic incision excises sinus and allows dissection of fistulous tract from surrounding tissues. b, Fistula is brought out through upper incision. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
Branchial Cysts and Fistulas
629
usual, occurs in the lower third of the neck, it is necessary to use multiple transverse incisions in stepladder fashion (Figs. 145 and 146). It is not uncommon to complete the entire operation through one incision. An elliptical incision is made around the orifice of the tract and the tract is meticulously dissected away from the surrounding structures. As the dissection is made cephalad beneath the sternocleidomastoid muscle, care is taken to identify the internal jugular vein, the common carotid artery and the vagus nerve. The tract usually passes between the internal and external carotid arteries. Above this level the hypoglossal
Fig. 146. Excision of branchial fistula. a, Digastric muscle is retracted upward; fistula is separated from surrounding structures and ligated close to wall of pharynx. b, Drain is inserted and wounds are closed with clips. (From Am. J. Burg., vol. 83, pp. 3-8, Jan., 1952.)
nerve is isolated and preserved. The posterior digastric muscle is retracted upward and the dissection is carried to the wall of the pharynx (Fig. 147). The tract is ligated and excised close to the pharynx in the region of the tonsil, most often in the fossa of Rosenmiiller. The results of this operation are excellent. Few if any recurrences should take place if the entire tract has been removed at operation. BRANCHIAL CYSTS
Branchial cysts occur equally in both sexes. Whereas in the case of branchial fistulas the greatest number occur in patients under the age'of 5, the greatest number of patients with branchial cysts are between 20 and 30 years of age. The cysts a.re found on either side, usually in close
630
Cornelius E. Sedgw'Lck
association with the anterior border of the sternocleidomastoid muscle, but differing from branchial fistulas in that they usually occur in the upper third rather than in the lower third of the neck (Fig. 148). The patient with 'a branchial cyst usually complains of a mass in the neck, not associated with pain. The cysts may vary in size from 1 cm. to 5 cm. Usually there is a history that the cyst has slowly increased in size.
Fig. 147. Anatomy involved in excising branchial fistula and cyst; "0" indicates usual site of external sinus. Arrow shows frequent location of fistulous tract between internal and external carotid arteries. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
Frequently, the patient gives a history of having had the mass incised and drained. Branchial cysts are more difficult to diagnose than are branchial fistulas. Branchial cysts may be mistaken for metastatic cervical neoplasms, lymphomas, tuberculous adenitis, dermoids, thyroid adenomas, thyroglossal cysts, cystic hygroma and carotid body tumors. It should be kept in mind that branchial cysts are always lateral cervical cysts, whereas thyroglossal cysts and dermoids are usually in the midline or close to the midline. Cystic hygromas are found in patients in a younger age group. Metastatic neoplasms should always be considered but, on palpation, they are usually harder and less discrete than branchial cysts. Furthermore,
Branchial Cysts and Fistulas
631
an intra-oral examination should always be made in an attempt to find a possible primary intra-oral or pharyngeal tumor. Tuberculous cervical adenitis is a constant problem in the diagnosis of lateral cervical tumors. This problem is not met as often in this country as}n other countries in
Fig. 148. a, band c, Typical branchial cysts in upper third and middle third of neck; d, atypical branchial cyst in lower third of neck extending beneath the sternocleidomastoid muscle into the posterior triangle. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
which unpasteurized milk is commonly used. In a patient who has a history suggestive of tuberculous adenitis and in whom there is a mass anterior to the sternocleidomastoid in the upper third of the neck, it may be difficult to determine whether such a tumor is tuberculous or a branchial cyst. Occasionally the diagnosis is made only at operation. Thyroid adenomas are usually easily distinguished from branchial cysts as the adenomas move when the patient swallows. Carotid body tumors are usually more deeply seated and cannot be displaced as easily
632
Cornelius E. Sedgwick
as branchial cysts. On occasion it may be necessary to aspirate a lateral cervical tumor for diagnosis. The fluid obtained may contain cholesterol crystals which are indicative of branchial cysts. Occasionally lipiodol is injected into the cyst for roentgenologic studies to outline its extent. The treatment of branchial cysts consists of enucleation and excision of the entire cyst. The type of incision used depends upon the size of the cyst. It may be transverse, oblique or longitudinal. In contrast to fistulas, a stepladder incision is rarely used for branchial cysts. The surrounding anatomical structures involved in excising the cyst are the same as those previously discussed relative to excision of a branchial fistula (Fig. 147). For the most part, surgical excision of branchial cysts gives very satisfactory results with few recurrences or sequelae.
Branchial Cysts and Fistu!as Clinical Aspects and Treatlllent CORNELIUS E. SEDGWICK
THE embryologic origin and pathogenesis of branchial cysts and fistulas have been described by Dr. Hicks (page 619). The purpose of this paper is to present the clinical manifestations and therapy of these neck tumors. Recently, we* studied the clinical aspects and treatment of 75 cases of branchial cysts and fistulas seen at the Lahey Clinic. It is apparent from this study that there are significant differences in the history and objective findings in these two conditions and that relative to diagnosis and treatment it is easier to think of branchial cysts and branchial fistulas as two distinct entities. BRANCHIAL FISTULAS
Branchial fistulas occur equally in males and females. The fistula is usually seen at birth or shortly thereafter. It may occur on either side and is usually unilateral but may be bilateral. Branchial fistulas appear as small dimples or pinpoint sized openings in the lateral region of the neck (Fig. 144). The opening is usually in close association with the anterior border of the sternocleidomastoid muscle, most often in the lower third of the neck, although sometimes in the middle third or even the upper third of the neck. Occasionally, the patient will state that the sinus drains more when he has a cold or upper respiratory infection. The diagnosis is not difficult. The only other common draining lateral cervical sinus is secondary to tuberculous adenitis. We believe that branchial fistulas should be excised when discovered except in the very young or in the presence of active inflammation. The operation consists of excising the entire tract from the external skin opening up to the entrance of the fistulous tract into the pharyngeal wall. The type of incision depends somewhat upon the location of the external opening and the length of the sinus tract. If the opening, as is
* Sedgwick, C. E. and Walsh, J. F.: Branchial cysts and fistulas: A study of seventy-five cases relative to clinical aspects and treatment. Am. J. Surg. 83: 3-8 (Jan.) 1952. 627
Cornelius E. Sedgwick
628
Fig. 144. Typical branchial fistula in a young boy. The fistula can be seen as a small dark area at the anterior border of the left sternocleidomastoid muscle in the lower third of the neck. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
FISTUL.DuS
TRACT
Fig. 145. Excision of branchial fistula. a, Lower transverse elliptic incision excises sinus and allows dissection of fistulous tract from surrounding tissues. b, Fistula is brought out through upper incision. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
Branchial Cysts and Fistulas
629
usual, occurs in the lower third of the neck, it is necessary to use multiple transverse incisions in stepladder fashion (Figs. 145 and 146). It is not uncommon to complete the entire operation through one incision. An elliptical incision is made around the orifice of the tract and the tract is meticulously dissected away from the surrounding structures. As the dissection is made cephalad beneath the sternocleidomastoid muscle, care is taken to identify the internal jugular vein, the common carotid artery and the vagus nerve. The tract usually passes between the internal and external carotid arteries. Above this level the hypoglossal
Fig. 146. Excision of branchial fistula. a, Digastric muscle is retracted upward; fistula is separated from surrounding structures and ligated close to wall of pharynx. b, Drain is inserted and wounds are closed with clips. (From Am. J. Burg., vol. 83, pp. 3-8, Jan., 1952.)
nerve is isolated and preserved. The posterior digastric muscle is retracted upward and the dissection is carried to the wall of the pharynx (Fig. 147). The tract is ligated and excised close to the pharynx in the region of the tonsil, most often in the fossa of Rosenmiiller. The results of this operation are excellent. Few if any recurrences should take place if the entire tract has been removed at operation. BRANCHIAL CYSTS
Branchial cysts occur equally in both sexes. Whereas in the case of branchial fistulas the greatest number occur in patients under the age'of 5, the greatest number of patients with branchial cysts are between 20 and 30 years of age. The cysts a.re found on either side, usually in close
630
Cornelius E. Sedgw'Lck
association with the anterior border of the sternocleidomastoid muscle, but differing from branchial fistulas in that they usually occur in the upper third rather than in the lower third of the neck (Fig. 148). The patient with 'a branchial cyst usually complains of a mass in the neck, not associated with pain. The cysts may vary in size from 1 cm. to 5 cm. Usually there is a history that the cyst has slowly increased in size.
Fig. 147. Anatomy involved in excising branchial fistula and cyst; "0" indicates usual site of external sinus. Arrow shows frequent location of fistulous tract between internal and external carotid arteries. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
Frequently, the patient gives a history of having had the mass incised and drained. Branchial cysts are more difficult to diagnose than are branchial fistulas. Branchial cysts may be mistaken for metastatic cervical neoplasms, lymphomas, tuberculous adenitis, dermoids, thyroid adenomas, thyroglossal cysts, cystic hygroma and carotid body tumors. It should be kept in mind that branchial cysts are always lateral cervical cysts, whereas thyroglossal cysts and dermoids are usually in the midline or close to the midline. Cystic hygromas are found in patients in a younger age group. Metastatic neoplasms should always be considered but, on palpation, they are usually harder and less discrete than branchial cysts. Furthermore,
Branchial Cysts and Fistulas
631
an intra-oral examination should always be made in an attempt to find a possible primary intra-oral or pharyngeal tumor. Tuberculous cervical adenitis is a constant problem in the diagnosis of lateral cervical tumors. This problem is not met as often in this country as}n other countries in
Fig. 148. a, band c, Typical branchial cysts in upper third and middle third of neck; d, atypical branchial cyst in lower third of neck extending beneath the sternocleidomastoid muscle into the posterior triangle. (From Am. J. Surg., vol. 83, pp. 3-8, Jan., 1952.)
which unpasteurized milk is commonly used. In a patient who has a history suggestive of tuberculous adenitis and in whom there is a mass anterior to the sternocleidomastoid in the upper third of the neck, it may be difficult to determine whether such a tumor is tuberculous or a branchial cyst. Occasionally the diagnosis is made only at operation. Thyroid adenomas are usually easily distinguished from branchial cysts as the adenomas move when the patient swallows. Carotid body tumors are usually more deeply seated and cannot be displaced as easily
632
Cornelius E. Sedgwick
as branchial cysts. On occasion it may be necessary to aspirate a lateral cervical tumor for diagnosis. The fluid obtained may contain cholesterol crystals which are indicative of branchial cysts. Occasionally lipiodol is injected into the cyst for roentgenologic studies to outline its extent. The treatment of branchial cysts consists of enucleation and excision of the entire cyst. The type of incision used depends upon the size of the cyst. It may be transverse, oblique or longitudinal. In contrast to fistulas, a stepladder incision is rarely used for branchial cysts. The surrounding anatomical structures involved in excising the cyst are the same as those previously discussed relative to excision of a branchial fistula (Fig. 147). For the most part, surgical excision of branchial cysts gives very satisfactory results with few recurrences or sequelae.