CYSTS & SINUSES OF

NECK
Dr. Veerabhadra Radhakrishna
 EMBRYOLOGY

 35 day foetus- four grooves- branchial clefts

 The intervening bars are the branchial

arches.

 Each arch contains a central cartilage.

 The clefts in human embryos are composed

of grooves on the outside and pouches on
the inside.
 The first cleft persists as the external auditory meatus, the second, third
and fourth clefts normally disappear.

 The whole, or a portion of one of the clefts that normally disappear may
persist. Alternatively, a portion can get sequestrated.
    Dorsal Ventral Midline floor
 Incus body
 Meckel’s cartilage
Arch  Malleus head  Body of tongue
 malleus
 Pinna
Cleft  Ext. auditory canal    
I
 Eustachian tube
Pouch    
 Middle ear cavity
Ext. maxillary A
     
Nerve V
 Root of tongue
 Styloid process  Foramen caecum
Arch  Stapes
 Lesser horn hyoid  Thyroid median
anlage
II
Pouch  Palatine tonsil
   
 Supratonsillar fossa
Stapedial A
     
Nerves VIII & VIII
 Greater horn & body
Arch   of hyoid  
 Part of epiglottis
III  Inferior parathyroid
Pouch  Thymus  
 Pyriform fossa
Internal Carotid A
     
Nerve IX
 Dorsal Ventral Midline floor
 Thyroid cartilage
 Cuneiform
Arch    
cartilage
 Part of epiglottis
IV
Pouch  Supr.    
Parathyroid
Arch of aorta (L)
Subclavian A (R)      
Nerve X
Arch      
V
Pouch  Ultimobranchial    
body
 Cricoid
 Arytenoid
Arch    
 Corniculate
VI cartilage
Pulmonary A
Ductus arteriosus (L)      
Rec. laryngeal N
 Neck Masses
 Midline Neck Masses
 Thyroid nodules
 Cervical Lymphadenopathy
 Thyroglossal Duct cyst
 Thymus gland anomalies
 Plunging ranula
 Lateral Neck Masses
 Branchial cleft anomalies
 Laryngoceles
 Dermoid and Teratoid Cysts
 BRANCHIAL CYST

 Vestigial remnants of 2nd branchial cleft.

 Lined by squamous epithelium.
 Contains clear fluid or toothpaste like
material.
 At ant. border of upper 3rd of
sternomastoid.
 Presents as a fluctuant, translucent
swelling.
 A rare variety is found lying closely
related to pharynx lined by columnar
epithelium and filled with mucus.
 BRANCHIAL FISTULA
 Unilateral or bilateral.
 Persistent second branchial cleft, the occluding
membrane of which has broken down.
 External orifice- lower 3rd ant border of
sternomastoid
 Internal orifice- ant aspect of the posterior pillar
behind the tonsil.
 Very often the track ends blindly being a sinus
rather than a true fistula. Track is invested with
muscle and lined by ciliated columnar epithelium
until destroyed by recurrent attacks of
inflammation.
Other Anomalies Encountered of Branchial Apparatus

 Branchial cartilage
 Cervical auricle
 Pharyngeal pouch
 Laryngocele
 Branchiogenic carcinoma
1ST BRANCHIAL POUCH REMNANT
Complications

 Recurrence
 Infection
 Nerve damage
 THYROGLOSSAL CYST
 A REMNANT OF THYROGLOSSAL DUCT
 The thyroid gland is developed from
the median bud of the pharynx (the
thyroglossal duct) which passes
from the foramen caecum at the base
of tongue to the isthmus of the
thyroid.

 Thyroglossal cyst may be present in

any part of the thyroglossal tract.
Anatomical Situations
 60% adjacent to hyoid
 25% above hyoid
 13% below hyoid
 8% intralingual

Cyst occupies midline, except in the region of thyroid

cartilage, where the thyroglossal tract is pushed to one
side, usually to the left.
The cyst may be lined by columnar, cuboidal and
occasionally squamous epithelium
 Midline neck swelling
 Fluctuant
 Non-translucent
 Moves with protrusion of tongue, upwards
 Moves with swallowing.
 Occurs equally between both sexes.
 Few cases present at birth, most in early childhood, upto 30% in
adulthood
 Cyst may present with infection.
 Ca-thyroid (papillary) has been rarely reported in a thyroglossal
cyst.
 A thyroglossal cyst should be excised because infection is inevitable due to
the presence of nodules of lymphatic tissue which communicate by
lymphatics with the lymph nodes of neck.

 The basic principle of the operation is to excise the entire cyst as well as the
thyroglossal tract upto its origin at foramen cecum; which requires removal
of the central portion of the hyoid bone.

 Recurrence results from failure to excise the entire tract to the base of
tongue.
 THYROGLOSSAL FISTULA

 Thyroglossal fistula is never congenital. It follows infection or inadequate

removal of a thyroglossal cyst.
 Long standing fistulas are inclined to be situated low down in the neck.
 Fistula is lined by columnar epithelium, discharges mucus and is frequently
the seat of recurrent attacks of inflammation.
 Treatment is by Sistrunk's operation where the entire track is excised upto
foramen caecum alongwith central core of body of hyoid cartilage and also
lingual muscles.
 LYMPHANGIOMA

 Lymphangiomas are benign masses with multinodular cysts of different

sizes and contents.
 Microcysts are less than 1 cm in diameter; macrocysts are greater than 1
cm in diameter and tend to be less invasive, less numerous, and less
difficult to remove.

 Both microcysts and macrocysts may contain blood and/or lymph, a

consequence of similar lymphatic and vascular embryology.
 In general, microcysts are more likely to contain blood and
macrocysts more likely to contain lymph.

 Macrocysts that contain lymph are also called cystic hygromas and
they are subsumed in the general category of lymphatic
malformations.
 Complications

 Investigations