Branchial Cleft Cysts and Fistulas
Introduction
Introduction to cleft palate and fistula The cleft palate cyst and the fistial tube (fractalcystandfistula), 76% to 90% are evolved from the second cleft palate and the embryonic residual tissue of the pharyngeal sac, less likely to be derived from the first or third to fifth cleft palate and the pharyngeal sac. Clinical manifestations of the anterior border of the sternocleidomastoid between the mandibular angle and the sternal fossa have a slowly increasing, unpushable mass and/or pupil, with a clear mucus overflow in the pupil. Local skin redness, swelling, tenderness, and swallowing pain or difficulty swallowing during infection. If the first cleft palate cyst and the fistula are complicated by hearing impairment and renal dysfunction, it is considered to be Branchi-Oto-Renal syndrome. Clinical surgical resection is an effective treatment. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: difficulty swallowing, fainting
Cause
Cleft palate cyst and fistula cause
(1) Causes of the disease
1. The cause of the first iliac crest tube. As the embryo matures, the first zygomatic arch (mandibular arch) and the second zygomatic arch (the lingual arch) gradually merge, and the first cleft palate is just the first zygomatic arch. The area formed by the second zygomatic arch is separated.
When the first zygomatic arch and the second zygomatic arch are not normally fused, the residual cells buried in the ventral side of the first iliac crest form a sinus or fistula with ectodermal epithelial tissue as the embryo develops, typically the first The position of the fistula is from the external auditory canal down to the lower side of the ipsilateral mandibular region. The outer hole of the fistula is mostly at the lower edge of the lower jaw, above the plane of the hyoid bone, and under the jaw between the sternocleidomast muscle and the midline of the neck. In the triangle area; the inner hole enters the cartilage of the external auditory canal. Therefore, the first iliac crest tube is also called the ear deaf tube. Except for the typical one, some of the fistulas are short, only to the cheek; some are inward and the first sac Communication occurs, so it enters the nasopharyngeal cavity in parallel with the eustachian tube. The fistula is open to the external auditory canal. The position and shape are different. Some are deep to the junction of the external ear canal and the bone, and some are shallow on the tragus and the tragus. Between, some openings are relatively large, the surrounding skin is slightly raised; some openings are small and difficult to find; some are connected to the external auditory canal and have no openings.
2. The second fistula fistula is caused by the second cleft palate or the second intima crest in the embryonic development. The clinical manifestations are the congenital cervical lateral fistula. There are three types according to the pupillary condition.
(1) Complete type: fistula with internal and external holes, most of which (80%) are located in the anterior margin of the sternocleidomastoid muscle in the lower third of the neck, and a few are located in the 1/3 or upper 1/ of the neck. 3.
(2) Incomplete type: a fistula with only an outer or inner bore;
(3) Recessive type: the inner and outer holes are locked, and only the middle part is not closed. This type will later evolve into a cyst.
(two) pathogenesis
The wall of the capsule and the wall of the vessel are mainly composed of connective tissue. The wall is mixed with muscle fibers and lymphoid follicles. There are also different degrees of inflammatory reaction. Lymphatic fluid accumulates in the peripheral tissues. Most of the capsule walls and the inner surface of the tube wall are stratified. Squamous epithelium, with hair follicles, sebaceous glands and sweat glands, part of the sac lined with ciliated columnar epithelium, the same as the respiratory epithelium, even with transient deformed epithelium, the squamous epithelium is the turbid water sample or emulsion; The main columnar epithelium is a thicker mucus and contains cholesterol crystals; in the case of intracapsular infection, it is a purulent liquid. If the cyst wall has thymus tissue (Hassall body), it is the third cleft palate and the derivative of the pharyngeal sac; For example, it contains thyroid tissue, which is derived from the fourth pharyngeal sac. In addition, there are reports of cochlear cysts and thyroglossal cysts coexisting.
Prevention
Cleft palate cyst and fistula prevention
1. If the fistula and cyst are found, please perform surgical treatment in time to avoid recurrent attacks and infections.
2. Pay attention to avoid oral hygiene, develop good oral hygiene habits for brushing your teeth in the morning and evening, and gargle after a meal.
3. Avoid cold, tired, moderate exercise, improve the body's immunity, so as not to secondary infection.
4. Avoid spicy food, avoid fried and fried foods, avoid smoking and drinking.
5. Keep the diet light, but need to pay attention to nutrient-rich, eat more foods rich in vitamins and cellulose, such as vegetables and fruits, and eat less greasy, high-fat foods.
Complication
Cleft palate cyst and fistula complications Complications, dysphagia, fainting
1. Cysts infected with cysts on the surface and surrounding skin redness, swallowing pain or difficulty swallowing, local tenderness, systemic fever and other infection symptoms, cysts empyema and ulceration, there may be pus self-discharge, long-term unhealed, forming a fistula.
2. The symptoms of vagus nerve stimulation are more common in the cervical canal, which is characterized by cough, hoarseness, pulse rate change, pale complexion, sweating, fainting and gastrointestinal symptoms, which are caused by stimulation of the vagus nerve.
3. Acute thyroiditis due to piriform sinus infection, piriform sinus cyst can be complicated by acute thyroiditis, which is characterized by redness and tenderness of the neck.
Symptom
Cleft palate cyst and fistula symptoms common symptoms pharyngitis swallowing difficulty purulent secretions difficulty breathing pale
1. The first cleft palate cyst and the fistula (cervical deafness) are rare. Most patients have pupils near the lower jaw angle shortly after birth. The diameter is usually no more than 1-2 mm, and there are viscous secretions. Pupils overflow, there are external auditory canal pupils, the external auditory canal also often have sticky or purulent secretions, but the tympanic membrane is normal, if the disease is complicated by hearing impairment and renal dysfunction, the Branchi-Oto-Renal syndrome.
2. The second fistula cyst and the fistula (neck side fistula)
(1) sac cyst: cysts can occur anywhere in the anterior border of the sternocleidoma between the mandibular angle and the sternal fossa, but most cysts occur in the upper 1/3 of the anterior border of the sternocleidomastoid muscle. Where, the cleft palate cyst is round, 3 ~ 5cm in diameter, the boundary is clear, soft, can not be pushed, sometimes the cord can be touched above the wall, the cyst size is relatively constant, can be slowly increased, such as cysts with small sinus and pharynx After the contents of the capsule are discharged, there is a strange smell and odor in the mouth, and the cyst shrinks. The bacteria invade the sinus through the pharyngeal sinus, causing secondary infection, which is characterized by redness and swelling of the surface of the cyst and its surrounding area. Infection symptoms such as difficulty in swallowing, local tenderness, and generalized fever.
(2) fistula fistula: caused by the second cleft palate and pharyngeal sac, the outer mouth is mostly located in the middle third of the anterior border of the sternocleidomastoid muscle, lower than the location of the cyst, unilateral fistula 90% of the total, bilateral are relatively rare, among the familial children, bilateral are more common, some people think that it is autosomal dominant inheritance, the primary fistula can be found in the neck after the birth of the pupil, continue Or intermittently spilling secretions, the pupil may also close for a period of time, and then appear again, the full-type fistula will have milk or water flowing out of the pupil when feeding and drinking water, when the pupil secretion is stopped, some patients Cough, hoarseness and dysphagia can occur, and some cough, hoarseness, pulse rate change, pale, sweating, fainting and gastrointestinal symptoms in the fistula exploration, which is caused by stimulation of the vagus nerve, and some The patient developed a complete fistula fistula after tonsillectomy.
3. The third fistula cyst and fistula (Piriform sinus cyst and sputum) The third cyst formed by the cervical cyst and fistula is rare, the fistula is located behind the common carotid artery, before the vagus nerve, its outer hole and the second The position of the outer hole of the fistula is basically the same, but the inner hole is in the pharyngeal crypt of the thyroid gland. The clinical location is on the left side of the neck. For example, the cyst is located in the pharynx, blocking the respiratory tract, and in the neonatal period. Can be onset, manifested as throat wheezing, and even breathing difficulties, childhood infection due to piriform sinus, often complicated by acute pharyngitis, a small number of acute thyroiditis, manifested as redness and tenderness of the neck.
4. The 4th, 5th device does not cause congenital malformation of the neck. They form the fistula, the left side of the lower aortic arch, the right side of the lower subclavian artery, the internal hole in the lower part of the throat, a few people outside The hole is above the collarbone.
Examine
Cleft palate cyst and fistula examination
X-ray inspection
(1) Neck radiograph of the neck: The air in the capsule is contained.
(2) esophageal barium angiography: visible barium into the sinus.
(3) fistula angiography: the contrast agent is injected into the Fogarty tube through the pupil, and the diagnosis can be confirmed according to the path of the device. Before the angiography, the pupil is sutured under the local anesthesia, so that the developer spreads along the fistula, and then the pressure is injected. Iodine oil or iodine water.
2. B-ultrasound showed no echogenic mass in the anterior cervical region, unilateral or bilateral, the mass was located above the hyoid bone, could not move up and down with swallowing, the mass of the mass was clear, there was a capsule, the wall was smooth, round, internal Poor sound transmission, visible weak spots, pressurized probe, the anteroposterior diameter of the mass is reduced (flattened), and retained for a long time.
Diagnosis
Diagnosis of cleft palate cyst and fistula
Diagnostic criteria
Diagnosis based on medical history and clinical manifestations is generally not difficult.
1. A fistula or cyst found after or after a medical history.
2. Clinical features The fistula or cyst occurs in the walking area of the lower jaw or the anterior border of the sternocleidomastoid muscle. The pupil has a transparent mucus overflow, and the subcutaneous fiber strip can be touched on the pupil.
3. Auxiliary examination X-ray and B-ultrasound showed characteristic images of cysts and fistulas in the walking area of the sputum.
Differential diagnosis
1. Cleft palate cysts need to be identified with the following diseases
(1) Acute submandibular lymphadenitis: It is a common disease in infants and young children. It is similar to the secondary infection of small cleft palate cysts. It is easy to be misdiagnosed. Before the infection of cleft palate cyst, there is a long history of cysts. After antibiotics and other infections control, the lymph nodes shrink, are substantial, can be active, and the cleft palate cyst is sexy and inactive.
(2) tuberculous lymphadenitis in the neck: lymph node cheese necrosis after liquefaction is also sac sexy, often confused with cleft palate cysts, tuberculous lymphadenitis lesions often have many lymph nodes around the inflammation, adhesion to each other, the lungs may have tuberculosis, The tuberculosis pure protein derivative (PPD) test is strongly positive and can eliminate cleft palate cysts.
(3) lymphangioma: small lymphangioma of the neck is similar to cleft palate cyst, but the former is often located in the posterior triangle of the neck, which is sac sexy, positive for light transmission test. B-ultrasound shows that lymphangioma is often multi-atrial and cleft palate For a single room, the wall is smooth, cystic puncture, lymphangioma is watery lymph, cholesterol-free crystal can be identified with cleft palate.
(4) thyroid nodules: sometimes cleft palate cysts and thyroid lobe adhesion or deep into the thyroid, radionuclide scanning is often cold nodules, thyroid function is normal, it is not easy to identify with cold thyroid nodules, should be cyst puncture The fluid was searched for the presence or absence of cholesterol crystals and puncture aspiration cytology for differential diagnosis.
(5) thyroglossal cyst: a few thyroglossal cysts that deviate from the midline of the neck are much like cleft palate cysts. The former moves up and down with swallowing, the cysts are stuck with the tongue tube, and the fluid in the capsule is free of cholesterol crystals.
2. Need to be identified with the following diseases
(1) thyroglossal fistula: a few of the scorpion scorpion scorpion that deviates from the midline of the neck is very similar to sputum, but the sacral cord of the former can be distinguished from the hyoid bone.
(2) tuberculous fistula of the neck: local history of repeated infections, multiple lymph nodes around the lesion, and adhesion to each other, lesions rupture discharge of cheese-like substances, lungs may have tuberculosis, strong positive PPD, etc. Diagnosis of sputum can be ruled out.
