Sutton Textbook Reading

Lesions of The temporal Fossa

and Parapharyngeal Region

Bagus Ronggonundarmo
 Congenital and Developmental
Anomalies

Branchial Cleft Anomalies

Known as Branchial Cleft Cyst
Congenital anomalies arising from the first
through fourth pharyngeal pouch
Most common  second cleft
First, third and fourth  rare
 Branchial Cleft Anomalies (Cyst)
• Congenital anomalies  birth
• Not obvious symptoms or symptomatic
• Symptoms  visible punctum on skin to Cyst
or neck masses
• Anomalies :
– Cyst
– Fistules
– Sinuses
 Etiology
• Incomplete involution of branchial cleft
structure
• 4 - 7 week of gestation  Involution failure
(incomplete involution)  anomalies (cysts,
sinuses or fistulea) according to their
branchial origin
• Cyst (the most commomn anomalies) 
branchial cleft cyst
Branchial cleft structure involution
Skemanya (jika ada)
 Epidemiology
• True incidence of branchial cleft anomalies is
unknown
• The most common congenital cause of a neck
mass
• No ethnic or gender predilection
• Mostly arise from second branchial cleft
• 10% anomalies are bilateral
• First branchial cleft cyst
– 5% to 25% of all branchial cleft anomalies
• Second branchial cleft cyst
– 40% - 95% of the branchial anomalies (the most
common anomalies)
• Third branchial cleft cyst
– Estimated represent 2% - 8% of all branchial cleft
anomalies
• Fourth branchial cleft cyst
– Extremely rare, 1% of all branchial cleft anomalies
 Physical examination
First branchial cleft cyst
• smooth, non-tender, flactuant mass , cutaneous
punctum (fluid may be expressed)
• Subclassified based on histology :
– Type 1
• ectoderm only, extremely rare, cyst lined by squamous
epithelium
• Pre-auricular masses or sinuses that track anterior and
medial to external auditory canal
– Type 2
• Both ectoderm and mesoderm, more common, contain skin
and cartilage structure
• Angle mandibulae or within sub-mandibulae region
Gambaran klinis
 Physical examination
Second branchial cleft cyst
• Tender (secondarily infected), External
punctum can be seen on the neck
• A pit or punctum of the skin lower anterior
border of sternocleidomastoid, tonsilla fossa
of pharynx, proximity of glossopharyngeal and
hypoglossal nerve, carotid vessel
• Anterior and medial to the
sternocleidomastoid (SCM) on the neck skin
Gambar klinis
 Physical examination
• Third and Fourth branchial cleft cyst
• Firm mass or infected cyst draining to
piriformis sinus or external neck skin opening
over middle to lower third of anterior the
sternocleidomastoid (SCM)
• Left side of the neck or suprasternal
notch/clavicular area
Gambar klinis
 Imaging studies
• Modalities can be used to determine a
branchial cleft anomalies :
– Sinogram  if a sinus track present
– Ultrasonography  determine cyst
characteristic
– Contrast- enhanced CT  depict a cystic
and enhanced mass in neck
– MRI  used for a finer resolution
 First branchial cleft cyst
• Ultrasound
– Sharply demarcated thin-walled cyst with variable
echogenicity: (depending on internal debris) anechoic
(most common)
• CT
– Sharply circumscribed, fluid density, and thin-walled mass,
variably and tend to increase with recurrent infections.
• MRI
– T1: variable signal dependent on protein content (high
protein content: high signal, low protein content: low
signal), T2: high signal, T1 C+ (Gd): no enhancement in
uncomplicated lesions
Gambar imaging
 Second branchial cleft cyst
• Ultrasound
– Sharply demarcated, posterior acoustic enhancement: 70%,
imperceptible walls: 82%,
– echogenicity is variable
• CT
– usually rounded or spheric, sharply circumscribed, fluid density
centrally, thin wall, extension of the cyst wall between the 
internal and external carotid arteries just above the carotid
bifurcation
– The notch sign, tail sign or beak sign  highly suggestive of the
diagnosis but not pathognomonic.
• MRI
– T1: variable signal dependent on protein content (high protein
content: high signal, low protein content: low signal), T2: usually
high signal, T1 C+ (Gd): no enhancement in uncomplicated
lesions
Gambar imajing
 Third and fourth branchial cleft cyst
• Radiologically difficult to distinguish third from
fourth branchial cleft abnormalities.
• Ultrasound  anechoic (uncomplicated
branchial cleft cysts), infection and hemorrhage
(increase echogenicity)
• CT  An may be seen as a fluid-attenuating,
typically unilocular, well-marginated mass lesion
(uncomplicated cyst)
• MRI  T1: hypointense to muscle (the presence
of proteinaceous debris can be hyperintense)
T2: hyperintense to muscle, T1 C+ (Gd):  rim
enhancement (infected cysts)
Gambar imajing
 Differential diagnosis
• Paramedian thyroglossal duct cyst
• Failure of normal development obliteration of
thyroglossal duct
– Ultrasound hypo / anechoic, thin wall, internal
vascularity (-), internal fluid (+) debris
– CT  thin-walled, smooth, well-defined homogenously
fluid-density lession. Location in anterior midline or 2 cm
of midline
– MRI  T1 : variable (low signal : low
protein/uncomplicated, high signal :
hemorrhage/infection), T2 : high signal, T1 C=(Gd) : no
enhancement-uncomplicated)
Gambar imajing
 Differential diagnosis
• Thyrid nodules
• Non neplastic benign nodules within thyroid
gland
• Ultrasound  iso- to hypoechoic, internal cyst
or heterogenous, calcification (+/-), multiple
echogenic foci with comey tail
 Cystic Hygromas
• Cystic variety of lymphangioma
• Located in cervico-facial region, axilla
• May compose of single or multipe lession
• Embriology  originate from sequestration of
lymphatic tissue from lymphatic sach (during
development lymphatic-venous sach)
Gambar klinis
 Cystic Hygromas
• Epidemiology 1 : 6000-16000live births
• 50-60% evident birth, 80-90% present by 2
years
• Location : cervico-facial region (posterior
cervical triangle), axilla, goin and below
tongue
 Cystic Hygromas
• Clinical manifestation  soft, compresible,
non-tender, transluminent and withput any
bruit
• Radiology modalities
• Ultrasound  multicystis lession, internal
septation, no blood flow (colour doppler).
Antenatal ultrasound  multiseptate, thin-
walled cyst mass, cpmlex echo texture (cystic
and solid)
 Cystic Hygromas
• CT Scan  multicystic, homogenous, non-
invasive density with low attenuation.
Evaluate the extent of lession and their
assosiation nerves and vessels
• MRI  hyperintense on T2-weighted and
hypointense on T1-weighted images
Gambar radiologis
 Haemangiomas
• Known as infantile hemangiomas
• Benign vascular neoplasma in head and neck
tumors of infancy
• Epidemiology  1-2% in neonates, 12% by 1
year of age. Female, caucasians and
premature neonates
• Pathology  proliferation growth of the
existing vessels and vassel formation
 Clinical presentation
• Blanching skin lession and develop fine
teleangiectasias
• Rad macule with a blanching halo (before
involution)
• Subcutaneous (deep) hemangimas  Bluish
nodul or plaque
Gambar klinis
 Radiographic features
• Ultrasound  predominantly superficial soft-tissue
lession  echogenic weel-defined mass with
prominent internal vascularity (color doppler)  high
flow arterial and low resistance venous waveform
• CT scan  lobulated mass, the same density to
adjacent muscles. A vivid and homogenous contrast
enhancement
• MRI  T1 : intermediate signal (between muscle and
fat). T2 : hyperintense, small area of hypointensity. T1
C+(Gd) : homogenous enhancemant