Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

626
Section 7
Trachea and Mediastinum
A
B
C
D
Figure 72-3. A and B, An incision is made in the posterior wall of the trachea. C and D, The defect is opened.
A
B
Figure 72-4. A fl ap is formed from redundant skin posterior to the trachea.

Chapter 72
Stenosis of the Tracheostoma Following Total Laryngectomy
627
A
B
Figure 72-5. The skin fl ap is transposed into the tracheal incision
and inset, and the stomal skin closure is completed.
Figure 72-6. Stomal revision using a skin fl ap.
PEARLS
• All efforts should be made to prevent stomal
stenosis by:
• Gentle handling of tissue
• Incorporation of the stoma into the laryngectomy
incision
• Careful approximation of skin to mucosa
• Elimination of compression forces and active
tension on the margin of the stoma
• Ensuring an adequate diameter to the stoma
• Patients with tracheal stoma stenosis should receive
a trial of conservative treatment of their problem
using a laryngectomy tube or a plastic stent.
• The possibility of recurrent cancer causing stenosis
should be ruled out by careful inspection, imaging,
and/or biopsy.
• The technique used should be as simple as possible
and be consistent with accepted surgical principles.
PITFALLS
• Recurrent cancer may cause narrowing of the
tracheal stoma. This possibility should be ruled out
before proceeding with revision surgery.
• Dilatation of the stoma with stents or a
laryngectomy tube may be a good solution to the
problem of stomal stenosis and the stoma should
not be revised before a trial with dilatation,
especially in the irradiated patient.
• The technique should be kept simple and the limited
blood supply of the peristomal skin should be
respected.
• Patients who have received radiation to the stomal
area should not be considered candidates for
revision of tracheal stenosis because of the
probability of poor healing and restenosis.
• Poor nutrition leads to poor wound healing.
Therefore the nutritional status of the patient should
be optimized before surgery in order to maximize
successful healing of the operated tissue.
References
1. Wax MK, Touma J, Ramadan HH: Tracheostoma stenosis after
laryngectomy: Incidence and predisposing factors. Otolaryngol
Head Neck Surg 113:242-247, 1995.
2. Giacomarra V, Russolo M, Tirelli G, Bonini P: Surgical treatment
of tracheostomal stenosis. Laryngoscope 111:1281-1284, 2001.
3. Bain J: Late complications of tracheostomy and prolonged endo-
tracheal intubation. Int Anesthesiol Clin 10:225-244, 1972.
4. Montgomery W: Stenosis of tracheostoma. Arch Otolaryngol
75:76-79, 1962.
5. Myers EN, Gallia LJ: Tracheostomal stenosis following total
laryngectomy. Ann Otol Rhinol Laryngol 91:450-453, 1982.
6. Montgomery W: Surgery of the Upper Respiratory System, 2nd
ed, vol 2. Philadelphia, Lea & Febiger, 1979.
7. Nauman HH: Kopf und Hals-chirurgie, band I. Stuttgart, Thieme
Verlag, 1972.

628
Section 7
Trachea and Mediastinum
8. Barbosa JF: Surgical Treatment of Head and Neck Tumors. New
York, Grune & Stratton, 1974.
9. Clairmont A: Tracheostoma construction during laryngectomy:
Techniques to prevent stenosis. J Laryngol Otol 92:75-78,
1978.
10. Jatho K: Das kanul en freie tracheostoma nack kehlkopf total
extirpation. Laryngol Rhinol 55:631-636, 1976.
11. Isshiki N, Tanabe M: A simple technique to prevent stenosis of
the tracheostoma after total laryngectomy. J Laryngol Otol
94:637-642, 1980.
12. Trail M, Chambers R, Leonard J: Z-plasty of tracheal stoma at
laryngectomy. Arch Otolaryngol 88:110-112, 1968.
13. Hartwell SW, Dykes ER: Construction and care of the end trache-
ostomy. Am J Surg 113:498-500, 1967.
14. Vlantis AC, Marres HAM, van den Hoogen FJA: A surgical tech-
nique to prevent tracheostomal stenosis after laryngectomy.
Laryngoscope 108:134-137, 1998.
15. Sani A: Carbon dioxide laser stomaplasty for tracheostomal ste-
nosis. J Laryngol Otol 112:467-468, 1998.
16. Bretteville G, Söberg R, Boysen M: An improved technique
for treating tracheostomal stenosis following laryngectomy. Clin
Otolaryngol 17:44-48, 1992.
17. Converse JM: An operation for relief of stenosis of the stoma fol-
lowing total laryngectomy. Arch Otolaryngol 52:950-951, 1950.
18. Maruyama Y, Kubota J, Nakajima H: A 5-fl ap procedure for repair
of stenosed tracheostoma. Acta Chir Plast 22:107-110, 1980.
19. Wax MK, Touma BJ, Ramadan HH: Management of tracheosto-
mal stenosis. Laryngoscope 109:1397-1401, 1999.

section 8
Neck
Chapter 73
Offi ce-Based Procedures: Fine-Needle
Aspiration Biopsy of a Mass in the Head
and Neck
Robert L. Ferris
Fine-needle aspiration biopsy (FNAB) has become a
standard technique in the initial offi ce evaluation of a
mass in the head and neck.1 These masses encompass
a variety of benign and malignant tumors and tumor-
like conditions that may present diagnostic challenges
to the surgeon and surgical pathologist. The high diag-
nostic accuracy of this technique makes it an attractive
alternative to traditional surgical biopsy. FNAB is par-
ticularly useful in sampling a mass in the salivary gland,2
identifi cation of classic papillary carcinoma and medul-
lary carcinoma of the thyroid, differentiation of colloid
goiter from follicular neoplasms,3,4 and confi rmation of
clinically suspicious lymph node metastases in patients
with documented or suspected malignant disease.
Needle biopsy has been practiced for more than
100 years and was popularized in the late 1920s by Dr.
Hayes Martin at Memorial Sloan-Kettering Hospital.5
However, he used large-bore needles under local anes-
thesia, and the technique did not enjoy widespread use
in the United States until fi ne-bore needles were intro-
duced. In this technique a fi ne-bore needle is intro-
duced into the mass under local anesthesia, cellular
material is aspirated, and a cytologic diagnosis is ren-
dered. Until recently, pathologists were reluctant to
diagnose malignancies on cytologic preparations. This
technique reliably differentiates reactive and infl amma-
tory processes that do not require surgical intervention
from neoplasia and benign from malignant tumors.
Thus, FNAB lends itself to the diagnosis of a palpable
mass in the head and neck, in particular, those that
persist after antibiotic treatment.
FNAB is safe, accurate, and cost-effective with
minimal complications and great patient acceptance.
The diagnosis is able to be known by the clinician
before surgery, and treatment modalities can then be
planned and discussed with the patient. Rates of false-
negative and false-positive diagnosis are low, and the
accuracy of detecting malignant lesions is high. If the
aspirate is nondiagnostic (which occurs in approxi-
mately 10% of cases, usually because of insuffi cient
material), FNAB should be repeated or excision consid-
ered if clinically indicated. A negative diagnosis does
not rule out malignancy, and if there is any suspicion
of malignancy, it may be necessary to repeat the FNAB
or perform an open biopsy of the mass. Recent large
studies have indicated high sensitivity and specifi city for
diagnostic evaluation of both epithelial and lymphoid
malignancies, thus enabling appropriate planning for
629

630
Section 8
Neck
staging and therapeutic purposes. Its overall diagnostic
accuracy is approximately 95% for all masses in the
head and neck, including 95% for benign lesions and
87% for malignant ones.6,7
In the case of lymphadenopathy, FNAB is the fi rst
step in evaluation, and a specifi c diagnosis is obtained
82% to 96% of the time.7,8 FNAB is especially useful in
the diagnosis of recurrent or metastatic tumors devel-
oping in previously irradiated areas. Although the value
of the test for metastatic carcinoma and recurrent lym-
phoma is accepted, its value in the initial diagnosis of
lymphoma remains controversial. With the advent of
sophisticated cellular immunologic methods such as
fl ow cytometry, characterization of different cellular
subsets within the aspirate population can be achieved
by staining for surface markers with fl uorescent anti-
bodies.9 Collection of a least two needle passes in Hanks’
basic salt solution or Roswell Park Memorial Institute
(RPMI) medium for immunophenotyping by fl ow
cytometry addresses some of the concerns with the ade-
quacy of FNAB specimens. Immunophenotyping by
fl ow cytometry detects cell surface antigens with a variety
of monoclonal antibodies that indicate differentiation,
lineage (B or T cells), and whether there is monoclonal
production of light chains or heavy chains.10 Immuno-
phenotyping also confi rms the reactive nature of the
lymph node because there will be a polyclonal pattern
of immunoglobulins with the production of both light
chains in a 2 : 1 κ : λ ratio. Gene rearrangement studies
can be performed when the results of immunopheno-
typing are equivocal, and this has led to a substantial
increase in accuracy for typing lymphomas.6 These are
the genes for cell surface antigen receptors, and arrange-
ment of these genes is the earliest genetic event in the
development of lymphomas. The gene rearrangement
can be detected by Southern blot technique or poly-
merase chain reaction. Even if open biopsy of a lymph
node has to be performed after FNAB, reactive, infl am-
matory, and metastatic lesions have been eliminated
and the diagnostic possibilities are narrowed down.
A negative diagnosis must be evaluated in light of
the clinical context because false-negative results occur
and a negative FNAB diagnosis does not rule out lym-
phoma. If the index of suspicion is high or if the lymph
node remains the same size or enlarges, excisional
biopsy should be considered. Forty-fi ve percent of non-
Hodgkin’s lymphomas, such as large cell, immunoblas-
tic, small noncleaved, and lymphoblastic lymphoma,
can be diagnosed by cytomorphologic examina -
tion alone. Diagnostic accuracy is high—90% to 96%
for metastatic carcinoma and 80% to 90% for
lymphomas.
Lymph node aspirates in children are more likely
to be reactive or infl ammatory.11 FNAB can be per-
formed in children, but if the child is younger than 2
to 3 years, immobilization may be necessary. Sedation
can be used in children between 2 and 7 years of age.
Children older than this are usually suffi ciently coop-
erative for FNAB to be performed without sedation or
other anesthetic techniques. If concern for patient
cooperation or safety exists, however, it is certainly pos-
sible to perform the procedure under a brief general
anesthetic. If an infl ammatory process is suspected or
if purulent material is aspirated, the specimen should
be triaged for microbiologic studies. In addition, special
stains can be performed on the cytologic smears. Myco-
bacteria appear as negative images on a Diff-Quik–
stained smear, and an acid-fast stain reveals the typical
beaded organisms. Culture or polymerase chain reac-
tion to confi rm the type of mycobacteria is also
essential.
Although patients may occasionally be apprehen-
sive initially, there are no signifi cant medical contrain-
dications to the FNAB procedure. A small hematoma
may occur at times, but signifi cant bleeding such as
might compromise the airway is extremely uncommon.
A pulsatile mass in the neck may represent the carotid
bulb or a carotid body tumor, and many surgeons prefer
to not aspirate the latter. However, the use of a fi ne-
gauge needle substantially reduces the chance of com-
plications developing, particularly if the mass can be
compressed by manual, external pressure. Cancer
seeding through the needle track was previously a
concern, but this appears to be more likely with large-
bore needles.
In the event of previously insuffi cient specimens,
FNAB can be performed by the pathologist or with a
cytopathologist nearby for real-time qualitative and
quantitative evaluation of specimen adequacy. The
advantages are that assessment of specimen adequacy
can be performed and additional needle passes made
if suffi cient material is not aspirated on the fi rst few
passes. This reduces the number of unsatisfactory speci-
mens. Depending on the initial diagnostic impression,
the specimen can be triaged appropriately. In many
institutions aspiration is performed in offi ces by clini-
cians who may not have immediate access to a patholo-
gist to perform the aspiration or even to assess adequacy
of the sample. In these circumstances, a minimum of
four separate needle passes and preparation of smears
of good quality produce optimal specimens for inter-
pretation. In any case, good communication with the
pathologist who is interpreting the results of FNAB is
of utmost importance. Correlation of the cytologic diag-
nosis with histopathologic fi ndings in the surgical speci-
men aids in developing a level of comfort with the
pathologist’s cytologic interpretation. In patients with
thyroid follicular lesions, only examination of multiple
sections of the excised nodule can establish or exclude
the presence of vascular or capsular invasion, fi ndings
that are necessary for distinguishing follicular adenoma
from follicular carcinoma. A proposed schema for
scoring cytologic specimen quality is provided in Table
73-1. Although this schema was designed for thyroid
cytologic analysis at the University of Pittsburgh, it may
be applicable to other types of masses.
PREPARATION FOR FINE-NEEDLE
ASPIRATION BIOPSY
The following equipment is used (Fig. 73-1): 20-mL
syringes; an optional syringe holder; glass slides with the

Chapter 73
Offi ce-Based Procedures: Fine-Needle Aspiration Biopsy of a Mass in the Head and Neck
631
Table 73-1 THYROID CYTOLOGY REPORT OF THE ADEQUACY OF ANALYSIS
Satisfactory for Interpretation
The specimen fulfi lls one of the diagnostic patterns below
Less Than Optimal
The specimen is at least modestly cellular but does not fulfi ll all requirements for the diagnostic categories below
(nonspecifi c pattern)
Unsatisfactory
The specimen fails to show one of the patterns below
Recommended Semiquantitative Grading of Adequacy
Background Grade
0—Bloody background with little or no colloid
1—Bloody background with little or no colloid and macrophages and/or infl ammatory elements
2—Defi nite areas of sharply demarcated watery colloid with typical wrinkles/crackled features on at least one slide, with
or without a bloody background, with or without macrophages and infl ammatory elements
3—Abundant sharply demarcated watery colloid with typical wrinkles/crackled features on many slides, with or without
macrophages and infl ammatory elements, minimal or no blood
Cellularity Grade
0—Less than 8 to 10 cellular fragments (at least 10 cells) on 2 slides
1—≥8 to 10 cellular fragments (at least 10 cells) on 2 slides
2—Cellular fragments (at least 50 cells) on 50% of the slides reviewed
3—Cellular fragments (at least 50 cells) on 100% of the slides reviewed
Cellular Preservation Grade
0—All slides are poorly preserved and diffi cult to evaluate because of mechanical disaggregation, obscuration as a result
of thick/bloody preparation, air drying, etc.
1—Most slides are poorly preserved and diffi cult to evaluate because of mechanical disaggregation, obscuration as a result
of thick/bloody preparation, air drying, etc.
2—Most slides are well preserved and diffi cult to evaluate because of mechanical disaggregation, obscuration as a result
of thick/bloody preparation, air drying, etc.
3—All slides are well preserved without mechanical disaggregation; obscuration is due to thick/bloody preparation, air
drying, etc.
Semiquantitative Adequacy Score (Add Grade from Each Category)
4 or less = inadequate—Repeat FNA
5 = inferior—Sensitivity of the study may be less than standard. Additional studies, including repeat fi ne-needle aspiration,
should be considered
6-7 = satisfactory—Specimen quality supports an optimally sensitive study
8-9 = superior—Specimen quality supports an optimally sensitive study
Courtesy Paul Ohori, MD.
Figure 73-1. Cytology slides, fi xative, a 20-mL syringe with a holder,
and a 22- to 25-gauge needle.
patient’s name written on the frosted end; 1- to 11/2-inch,
21- to 25-gauge needles; 95% alcohol or a spray fi xative
to fi x the slides; alcohol swabs and gauze pads; and a
balanced salt solution for rinsing the needle.
In the preparatory phase a clinical history is
obtained, a directed physical examination is performed,
and informed consent may be obtained. The patient is
positioned comfortably (Fig. 73-2). In the case of thyroid
aspiration, the neck is extended with a pillow under the
shoulders. The person performing the aspiration may
be more comfortable standing on the side opposite the
mass. Often, the aspirator and the interpreter are two
different persons, and clear communication between
the two is vital. Thus, it is essential that the pertinent
clinical history be documented on the requisition form,

632
Section 8
Neck
including previous attempts at biopsy and previous
treatments. The number of needle passes, along with a
gross description of the aspirate, can be documented
on the form. In addition, in the event that a cystic mass
is aspirated, the volume of fl uid that was removed from
the mass should be recorded. The syringe containing
this material should be sent to cytopathology to be
“spun down” and made into a cell block for paraffi n
embedding and microscopic examination.
TECHNIQUE OF FINE-NEEDLE
ASPIRATION BIOPSY
A syringe with 1 mL of air in it is placed in the optional
syringe holder.12 The area is cleaned with an alcohol
swab. Because of the fi ne bore of the needle, local
anesthesia is optional and most patients tolerate the
procedure well. However, we infi ltrate the biopsy site
with 1% lidocaine with a 1:100,000 dilution of epineph-
rine. The mass is fi xed between two fi ngers of the non-
dominant hand, and the skin is stretched slightly to
reduce pain. The needle is introduced into the mass.
Vacuum is created by pulling back on the plunger
of the syringe. In the case of thyroid aspiration, the
patient is advised to not swallow while the needle is in
the mass. The needle is moved in and out of the mass
in short vibratory strokes for a distance of 2 to 3 mm
(Fig. 73-3). It is important that the direction of the
needle not be changed while it is in the mass. Signifi -
cant manipulation of the needle within the mass can
lead to disruption of blood vessels, which increases
the morbidity of the procedure and compromises the
quality of the specimen. As soon as material enters
the hub of the needle, the vacuum is released, the
needle is removed from the mass, and pressure is
applied to stop bleeding.
The aspiration technique in thyroid nodules in
children can be alternated with a nonaspiration
technique. The needle is introduced without an
attached syringe or without suction in the syringe. If a
cyst is suspected, the syringe may be attached with
the plunger removed. For thyroid lesions or those
that yield bloody specimens, needle passes without the
application of negative pressure are sometimes useful,
and suffi cient cellular material can be introduced into
the needle hub for cytopathologic analysis. The needle
is moved in and out of the mass in short vibratory
strokes, and the needle may be rotated. After 15 to 20
strokes, the needle is withdrawn and pressure applied.
The material is expelled onto slides after attaching a
syringe. A minimum of four separate needle passes is
made.
SPECIMEN HANDLING
The aspirated material is expelled onto two slides, with
the beveled edge of the needle touching the slides,
which have previously been labeled with the patient’s
name. Smears are prepared by placing the surfaces of
the two slides containing the specimen against each
other and drawing one slide along the long axis of the
other. One smear may be air-dried and the other one
immediately wet-fi xed in 95% ethyl alcohol, or the slide
may be spray-fi xed from a distance of 8 to 10 inches.
The needle is then rinsed in a balanced salt solution.
Normal saline is not recommended because it is not
physiologic. The specimen may be specifi ed for micro-
biologic studies or sent for immunophenotyping by
fl ow cytometry. Every effort should be made to have the
slide processed and read immediately while the patient
is still in the offi ce. If the FNAB is unsatisfactory, it can
be repeated without the need for the patient to return
another day.
Recently, ultrasound-guided FNAB has gained
acceptance in the surgeon’s offi ce. This technique is
particularly useful in detecting metastatic or recurrent
disease in known cases of malignancy or in localizing
masses in the third dimension for obtaining a cyto-
Figure 73-2. The patient is positioned comfortably with a headrest.
The surgeon may stand opposite the mass to secure it manually. The
needle is introduced and multiple (15 to 20) short passes are made
until material is observed within the needle hub. If excessive blood is
noted, suction can be reduced or eliminated and passes continued
through the mass.
Figure 73-3. The needle is moved in and out of the mass in short
vibratory strokes for a distance of 2 to 3 mm.

Chapter 73
Offi ce-Based Procedures: Fine-Needle Aspiration Biopsy of a Mass in the Head and Neck
633
pathologic specimen.13 Advantages include improved
specimen quantity and quality, as well as reduced waiting
times by avoiding delay caused by scheduling a proce-
dure in the radiology suite.
In any cystic lesion of the neck, a rule of thumb is
to empty the cyst and aspirate any residual mass or the
capsule of the cyst to avoid missing a cystic carcinoma.
Occasionally, computed tomography–guided FNAB
may be necessary to specifi cally sample a solid-appear-
ing mural nodule in a cyst that is not palpable in the
offi ce. Usually, however, cystic mass aspirates can be
adequately diagnosed by an experienced cytopatholo-
gist. The differential diagnosis of cystic lesions in the
neck is quite extensive and includes benign cysts such
as branchial cleft cysts, thyroid and thyroglossal cysts,
parathyroid cysts, and Warthin’s tumor. Malignant
cystic lesions include papillary carcinoma of the thyroid,
mucoepidermoid carcinoma of the parotid gland, and
cystic squamous carcinoma metastatic to a lymph
node.14
FNAB is also indicated for the diagnosis of parotid
masses because open or large-bore needle biopsy may
traumatize the facial nerve or produce tumor seeding
of the skin and soft tissue with the risk of recurrent
disease. Many lesions thought to be neoplasms on clini-
cal examination are often intraparotid lymph nodes,
localized sialadenitis, benign lymphoepithelial lesions,
or cysts. FNAB diagnosis of a lymphoepithelial lesion or
lymphoma of the parotid gland in patients with acquired
immunodefi ciency syndrome averts surgery in this
group of high-risk patients. FNAB of salivary glands is
up to 90% accurate and is better for diagnosing benign
than malignant tumors. FNAB has a sensitivity of 90%
and a specifi city of 80% for the salivary glands. False-
positive rates in different series have varied from 0% to
4.7%.
In summary, FNAB is a highly useful technique in
the algorithm for offi ce-based evaluation of cervical
masses. There should be good communication between
the clinician and the cytopathologist, with both working
as a team, which will lead to an optimal cytologic diag-
nosis and result in good patient care. FNAB of a mass
in the head and neck is an optimal way to make a diag-
nosis, and in the present managed care environment,
it is an ideal technique for making a diagnosis in a quick
and cost-effective manner.
References
1. McGuirt WF: The neck mass. Med Clin North Am 83:219-234,
1999.
2. Layfi eld LJ, Glasgow BJ: Diagnosis of salivary gland tumors by
fi ne-needle aspiration cytology: A review of clinical utility and
pitfalls. Diagn Cytopathol 7:267-272, 1991.
3. Gharib H, Goellner JR: Fine-needle aspiration biopsy of the
thyroid: An appraisal. Ann Intern Med 118:282-289, 1993.
4. Singer PA: Evaluation and management of the solitary thyroid
nodule. Otolaryngol Clin North Am 29:577-591, 1996.
5. Martin H: Surgery of Head and Neck Tumors. New York, Harper
& Row, 1957.
6. Vianello F, Tison T, Radossi P, et al: Detection of B-cell mono-
clonality in fi ne needle aspiration by PCR analysis. Leuk Lym-
phoma 29:179-185, 1998.
7. Prasad RR, Narasimham R, Sankaran V, Veliath AJ: Fine-needle
aspiration cytology in the diagnosis of superfi cial lymphadenopa-
thy: An analysis of 2,418 cases. Diagn Cytopathol 15:382-386,
1996.
8. Ellison E, LaPuerta P, Martin SE: Supraclavicular masses: Results
of a series of 309 cases biopsied by fi ne needle aspiration. Head
Neck 21:239-246, 1999.
9. Cannon CR, Richardson LD: Value of fl ow cytometry in the evalu-
ation of head and neck fi ne-needle lymphoid aspirates: A 3-year
retrospective review of a community-based practice. Otolaryngol
Head Neck Surg 124:544-548, 2001.
10. Nayak JV, Cook JR, Molina JT, et al: Primary lymphoma of the
larynx: New diagnostic and therapeutic approaches. ORL J Oto-
rhinolaryngol Relat Spec 65:321-326, 2003.
11. Ramadan HH, Wax MK, Boyd CB: Fine-needle aspiration of head
and neck masses in children. Am J Otolaryngol 18:400-404,
1997.
12. Dusenbery D: The technique of fi ne-needle aspiration of palpa-
ble mass lesions of the head and neck. Op Tech Otolaryngol
Head Neck Surg 7:61-67, 1997.
13. Kraft M, Lang F: A modifi ed technique of ultrasound-guided
fi ne-needle aspiration in the diagnosis of head and neck lesions.
Laryngoscope 116:497-498, 2006.
14. Ferris RL, Branstetter BF, Nayak JV: Diagnostic utility of positron
emission tomography–computed tomography for predicting
malignancy in cystic neck masses in adults. Laryngoscope
115:1979-1982, 2005.
PEARLS
• The ability to discriminate benign from malignant
cervical masses, rapid assessment, potential
avoidance of surgical intervention, low complication
rates, and cost-effectiveness have made FNAB
diagnosis of head and neck masses the standard of
care.
• FNAB for thyroid follicular lesions cannot
differentiate benign from malignant neoplasms.
PITFALLS
• Exposure of cytology slides to air for prolonged
periods before fi xation leads to air-drying artifact,
which limits the quality of the specimen.
• Using high suction (negative pressure) in the syringe
will predispose to bloody cytologic specimens that
can be diffi cult for the cytopathologist to interpret.
• A single negative FNAB should not be overweighted
in the context of other suspicious clinical data, and
concern for malignancy should prompt further
cytologic or histologic analysis of the mass in the
neck.
• A cystic nodule in the lateral aspect of the neck
demonstrating numerous proliferating squamous
cells raises the possibility of metastatic papillary
carcinoma of the thyroid or metastatic squamous
cell carcinoma, usually from the base of the tongue
or tonsil.

Chapter 74
Thyroglossal Duct Cyst
Eugene N. Myers
A thyroglossal duct cyst (TGDC) is the most common
mass encountered in the midline of the upper part of
the neck. Although a TGDC may develop at any loca-
tion along the thyroglossal duct tract, it is most com-
monly manifested as an upper midline cervical mass,
usually adjacent to the hyoid bone and thyrohyoid
membrane. TGDC may also be found in the submental
space or as a low cervical mass.1 Because thyroid devel-
opment occurs along the midline of the neck, the cyst
rarely occurs in a lateral position. Recently, however, six
cases of intrathyroid TGDC have been reported in the
literature (two children2 and four adults3,4).
Successful management of thyroglossal duct rem-
nants must be based on an understanding of the embry-
ology and developmental anatomy of the thyroid gland.5
The thyroid anlage appears in the 2.0- to 2.5-mm embryo
as a midline structure and projects downward from the
fl oor of the pharynx at a point that corresponds to the
foramen cecum in adults.6 During the course of devel-
opment, the thyroid descends along the midline to its
position in the anterior aspect of the neck, where it
forms a tract known as the thyroglossal duct and main-
tains an attachment to the base of the tongue. The
hyoid bone divides this tract into upper and lower seg-
ments during the second embryologic month, when the
thyroid gland assumes its fi nal position anterior to the
trachea in the root of the neck, at which time the tract
is resorbed. The hyoid bone arises from the second
branchial arch and grows forward after descent of the
thyroid. Rotation of the hyoid during its development
results in the thyroglossal duct being drawn posteriorly
and cranially at the inferior margin of the bone. Fusion
of the second branchial arch anlage in the midline
may result in entrapment of the thyroglossal duct by
the hyoid bone. Dr. Sistrunk, who understood the
developmental anatomy, included removal of the body
of the hyoid as a fundamental step in the prevention
of recurrence. Failure of the resorption process, or
the presence of retained epithelial rests along the
tract, forms the basis for the development of a TGDC.
No communication occurs between the thyroglossal
duct remnant and the skin because of the absence of
embryologic communication in some branchial cleft
abnormalities.
The differential diagnosis of a midline cervical mass
includes
• Thyroglossal duct cyst
• Dermoid cyst
• Lipoma
• Hemangioma
• Fibroma
• Cervical lymphadenopathy
In a series of 1316 cases reported in the literature,
31% of the patients were younger than 10 years, 20.4%
were in their second decade of life, 13.5% were in their
third decade, and 34.6% were older than 30 years.7 We
reviewed the results of the University of Pittsburgh
TGDCs in adults and identifi ed 45 patients older than
18 years in a group of 104 patients.8 TGDCs occur
equally in both genders as demonstrated by Allard in a
series of 1747 patients with TGDCs collected from the
literature,7 in which 870 were male and 877 were female.
Although most develop in childhood, a TGDC may not
become clinically apparent until well into adulthood.
Approximately 0.6% of such cysts are found in patients
older than 60 years,9 and only 8 cases of TGDC have
been reported in patients 70 years or older.10-12 Though
unusual, cancer involving TGDCs has been reported.13
These authors recommended removal of all suspected
TGDCs in the elderly because of the notable rate of
malignant transformation in their series. Fine-needle
635

636
Section 8
Neck
A
B
Figure 74-1. Thyroglossal duct cysts may be large (A) or small (B) on initial evaluation.
h
aspiration biopsy (FNAB) may be helpful in identifying
cancer preoperatively in this population.
PATIENT SELECTION
Surgical excision of a mass in the midline of the neck
is performed for diagnostic and therapeutic purposes.
The following are indications for excision of what
appears to be a TGDC:
• The presence of an undiagnosed mass
• Cosmetic appearance
• A history of infection in the mass
• The possibility of cancer originating in a TGDC
On initial evaluation, TGDCs may be relatively
small or very large (Fig. 74-1). Some patients have a
history of current or recurrent infection. In some cases,
incision and drainage, packing, and antibiotics have
been used to treat an abscess in this area without the
treating physician recognizing that it is an infection in
a TGDC. In these circumstances, recurrent infection is
to be expected. Patients may also have a history of
chronic drainage from the mass if previous incision plus
drainage has been performed or an attempt that is less
extensive than a Sistrunk procedure has been made to
remove a TGDC.
Carcinoma arising in a thyroglossal duct remnant
was fi rst reported in 1925 by Ashurst and White.14 Since
that time more than 100 such cases have been reported.7
Rampaul and coauthors found 160 cases published in
the literature in the past 85 years.15 Patients in these
series range in age from 6 to 91 years, with an average
age of 39.2 years. Most of the patients were in the third
through the sixth decades of life. Cancer occurs more
frequently in females than in males. The diagnosis of
carcinoma is seldom made defi nitively preoperatively;
however, the presence of calcifi cation in a TGDC on
imaging studies suggests papillary carcinoma (Fig. 74-2)
because these areas of calcifi cation are psammoma
bodies, a histologic hallmark of papillary carcinoma.
The fi rst case of a benign TGDC with psammoma bodies
was reported in a 3-year-old patient.16 It has been sug-
gested that the presence of calcifi cation in association
Figure 74-2. Calcifi cation in an imaging study of a thyroglossal duct
cyst raises suspicion of papillary carcinoma arising in a thyroglossal
duct cyst. h, hyoid bone; long arrow, calcifi cation; open arrows, thyro-
glossal duct cyst.
with a TGDC may be a specifi c radiologic marker for
carcinoma.17 The diagnosis of carcinoma arising in a
TGDC is usually made histologically after the mass has
been excised. Pathologic diagnoses in these cases
include papillary adenocarcinoma, follicular adenocar-
cinoma, mixed papillary and follicular adenocarcinoma,
adenocarcinoma, and squamous cell carcinoma.7
Management of carcinoma arising in a TGDC
remains somewhat controversial because this problem
is encountered relatively infrequently (<1%). When the
diagnosis of carcinoma is made, a radionuclide scan

Chapter 74
Thyroglossal Duct Cyst
637
with radioactive iodine (131I) is performed. If the thyroid
gland appears normal, thyroidectomy is not necessary.
Suppression of thyroid-stimulating hormone with
thyroid hormone is initiated, along with systematic
follow-up and serial determination of thyroglobulin
levels. Resection of a TGDC by the Sistrunk procedure
has been demonstrated to be oncologically adequate in
the management of differentiated thyroid carcinoma in
the absence of extracapsular extension, lymph node
metastasis, or thyroid abnormality. If a cold nodule is
found in the thyroid gland, thyroidectomy should be
performed with central compartment nodal dissection.
Neck dissection is indicated if cervical metastasis is iden-
tifi ed. Ultrasound-guided fi ne-needle aspiration may
also be useful in the setting of possible cancer in a
TGDC.
TGDCs can produce a variety of symptoms ranging
from the mere presence of the mass to dysphagia,
coughing, a choking sensation, or upper respiratory
obstruction. Airway obstruction is a serious, though rare
complication that may occur as a result of involvement
of the preepiglottic space. Lübben and colleagues
reported a 62-year-old man with progressive respiratory
obstruction from a 5 × 3 × 2-cm bilobed mass that
extended through the preepiglottic space into the
larynx.18 The authors also noted that three cases of inva-
sion of the larynx with a TGDC had been reported by
Slotnik and associates.19 Brown and coauthors reported
a 37-year-old patient with complaints of a sore throat, a
choking sensation, and diffi culty breathing while recum-
bent.20 Invasion of the anterior larynx by a TGDC fi lling
the preepiglottic space was found on computed tomog-
raphy (CT). No patient in our series experienced respi-
ratory obstruction.8
TGDCs are, on average, 1 to 2 cm in size but may
range up to 10 cm.7 The mass is nontender unless it is
infected. The skin will be freely movable over the cyst
unless the cyst has been or is currently infected. Char-
acteristically, the mass moves with swallowing or protru-
sion of the tongue, which refl ects attachment to the
hyoid bone. If the patient has a midline mass in the
neck that does not move with swallowing, a pathologic
entity other than a TGDC should be considered. If
there is no history of infection in the mass, it is often
possible for the examiner to confi rm the diagnosis via
palpation of the thyroglossal duct by grasping the mass
between the thumb and forefi nger and reaching toward
the hyoid bone (Fig. 74-3).
PREOPERATIVE PLANNING
The history and physical examination have remained
the mainstay for diagnosis and therapeutic decision
making relative to TGDCs. However, a number of
studies have been proposed to aid in the diagnosis of a
midline neck mass:
• Ultrasonography
• High-resolution CT
• Magnetic resonance imaging (MRI)
• Radionuclide scanning
• FNAB
Radionuclide studies are helpful in identifying
functional thyroid tissue and distinguishing it from
other nonthyroid abnormalities. Radioisotopic scan-
ning identifi es functioning thyroid tissue in a TGDC
in approximately a third of patients. Thyroid scanning
is reliable in confi rming the presence of functioning
thyroid tissue outside the TGDC itself. The scan, there-
fore, is not done specifi cally to diagnose a TGDC but is
used to eliminate the possibility of mistaking an ectopic
thyroid gland for a TGDC. Advocates of routine preop-
erative radioactive scanning of the thyroid gland in
children with suspected TGDCs note the substantial
frequency of ectopic thyroid tissue manifested as a mass
in the midline of the neck in the absence of a function-
ing thyroid gland lower in the neck.21 Excision of a
misdiagnosed ectopic thyroid gland will result in post-
operative hypothyroidism. The literature contains
reports of myxedema after inadvertent excision of a
mass in the neck that proved to be the only functioning
thyroid tissue. Radkowski and coworkers22 reported fi ve
of eight patients with an ectopic thyroid or thyroid
nodule in their review who had a preoperative history
suggestive of hypothyroidism. They suggest that a
careful history and physical examination to establish
whether there are symptoms suggestive of hypothyroid-
ism, including fatigue, chronic constipation, develop-
mental and growth delay, and excessive somnolence on
waking, will aid in identifying patients with ectopic
thyroid tissue who are at risk for the development of
postoperative myxedema. If there is suspicion of hypo-
thyroidism, they suggest that thyroid function tests be
Figure 74-3. The thyroglossal duct may be palpated deep to the
cyst.

638
Section 8
Neck
performed. Any abnormality on these tests should
prompt a preoperative nuclear scan to rule out ectopic
thyroid tissue. The authors present an algorithm for the
management of anterior neck swelling (Fig. 74-4).
Ahuja and associates23 recommend high-resolution
ultrasound for ideal initial investigation, especially in
children, because it does not require ionizing radiation
or sedation, is readily available and inexpensive, and
provides the surgeon with the necessary preoperative
information. The authors studied 23 children with
TGDCs via ultrasound and concluded that TGDCs in
children are not simple cysts but have a complex pattern,
including anechoic (13%), pseudosolid (56.5%), and
heterogeneous (30.5%) areas.23
The success of CT and MRI in detecting TGDCs is
also well documented.24,25 King and coworkers26 investi-
gated the utility of MRI in 16 patients with TGDC via
T1, T2, and T2 fat saturation images. Contrast-enhanced
images were obtained in fi ve patients. They concluded
that TGDCs most commonly have high T1 signal inten-
sity because of the high protein content in the fl uid.
The tract leading to the base of the tongue is infre-
quently seen, the diagnosis being determined by the
intimate relationship to the hyoid bone and strap
muscles. Intralaryngeal extension of TGDCs was noted
more frequently in adult patients than had been
reported previously.
FNAB has gained popularity in recent years because
it is a simple, rapid, and inexpensive technique with low
complication rates.27 FNAB is not used routinely in the
diagnosis of TGDC. Although the diagnostic criteria for
TGDC and papillary carcinoma have been well defi ned,
FNAB fails to achieve an accurate preoperative diagno-
sis of papillary carcinoma in TGDCs.
Astl and coauthors28 described their experience
with TGDCs and cancer of the thyroid in three patients
and reviewed the literature. They used clinical and
ultrasound examination and FNAB for preoperative
assessment. Diagnostic and therapeutic procedures
included both thyroglossal duct remnant excision
(Sistrunk or Schlange procedure) and total thyroidec-
tomy. Postoperative radiation therapy or radioiodine
ablation was used in cases of carcinoma arising in a
thyroglossal duct remnant or carcinoma of the thyroid
associated with a thyroglossal duct remnant. Although
the therapeutic approach could be a matter of discus-
sion, most patients agreed with their suggestion of rela-
tively radical but nonmutilating treatment.
On the other hand, Patel and colleagues29 reviewed
57 evaluable patients with well-differentiated thyroid
carcinoma arising in a TGDC who were reported in the
recent literature, as well as 5 cases of their own. A
Sistrunk procedure was performed for the TGDC in the
majority (90%) of patients. Papillary carcinoma was the
most frequent (92%) histologic type. Total thyroidec-
tomy was performed after the diagnosis of TGDC carci-
noma in approximately half of the 62 patients. A
malignant tumor was found in 27% of the thyroidec-
tomy specimens. Postoperative 131I was administered to
16 (26%) of the patients. There were no disease-related
deaths reported in any of these patients. Univariate
analysis revealed that the only predictor of overall
disease-free survival was the extent of primary surgery
for the TGDC. The addition of total thyroidectomy to
the Sistrunk procedure did not have a signifi cant impact
on outcome. The Sistrunk procedure is adequate for
most patients with incidentally diagnosed TGDC carci-
noma in the presence of a clinically and radiologically
normal thyroid gland. The results of the Sistrunk
operation with adequate excision are excellent, and the
concept of risk groups should be used to identify
patients who would benefi t from more aggressive
treatment.
DESCRIPTION OF SURGERY
In 1893, Schlange described a procedure that included
removal of the midportion of the hyoid bone in conti-
nuity with the cyst.30 The Sistrunk procedure extended
the Schlange procedure by also including resection of
a portion of the base of the tongue and has been the
standard surgical approach for TGDCs since it was fi rst
described in 1920.31 The Sistrunk procedure has
achieved excellent results, with recurrence rates between
1.5% and 4%.32 The operation is based on precise
knowledge of the embryology and developmental
anatomy of the thyroglossal duct. The operation
includes excision of the cyst in continuity with the mid-
portion of the body of the hyoid bone and a block of
muscle that theoretically includes the thyroglossal duct
remnant dissected up to its origin in the area of the
foramen cecum.
Brereton and Symonds32 reported a 38% recur-
rence rate in 50 patients in whom the hyoid bone was
not resected or the duct above the hyoid bone was dis-
sected with an inadequate margin of surrounding
muscle. Although excellent results with the Sistrunk
Comprehensive
history/physical examination
Anterior Midline Neck Swelling
Symptoms
of
hypothyroidism
Clinically euthyroid
Laboratory testing
Normal TFTs
Surgery
TGDC
Thyroid tissue
Abnormal TFTs
(elevated TSH)
Thyroid
scan
Figure 74-4. Algorithm for evaluation of a midline neck mass.
TFTs, thyroid function tests; TGDC, thyroglossal duct cyst; TSH,
thyroid-stimulating hormone.

Chapter 74
Thyroglossal Duct Cyst
639
procedure have been obtained, it is clear that trouble-
some recurrences are still encountered. Marianowski
and coauthors6 reported a series of 74 patients who
underwent a Sistrunk procedure for the preoperative
diagnosis of TGDC. Fifty-seven were confi rmed histo-
logically as TGDCs. Recurrence was noted in 15% of
confi rmed TGDCs. Four individual risk factors have
been identifi ed: number of infections before surgery,
previous surgical procedure, age (<2 years), and multi-
cystic lesion on histopathology.
The operation is carried out under general anes-
thesia with the patient in the supine position. A folded
blanket, or a towel in younger children, is then placed
beneath the shoulders to extend the head. The trans-
verse incision is placed in the midline in the major skin
crease in the upper part of the neck to achieve a fi ne
scar (Fig. 74-5A).
A
B
C
D
If a draining sinus is present or if the cyst has previ-
ously been infected and the skin is adherent to the cyst,
an elliptical incision is made such that the sinus tract
or involved skin is removed with the specimen. The
incision is carried down through fat and subcutaneous
tissue. The inferior fl ap does not usually require much
elevation, whereas the fl ap superior to the hyoid bone
must be elevated to allow adequate resection. The strap
muscles are identifi ed, an incision is made to facilitate
separation of the strap muscles, which may already be
separated by the cyst, and blunt retractors are used to
retract the strap muscles. Via sharp and blunt dissec-
tion, the cyst is then dissected free of the thyroid carti-
lage and thyrohyoid membrane and pedicled on the
hyoid bone superiorly (see Fig. 74-5B). In patients who
have not had infection, the planes are easily identifi ed,
thus making dissection straightforward. However, in
Figure 74-5. A, The incision is placed in the major skin crease in the midline of the neck. B, The cyst is identifi ed, the strap muscles are
retracted, and the cyst is pedicled on the hyoid bone. C, The hyoid bone is grasped with a tenaculum and skeletonized. D, The hyoid bone is
transected with a bone cutter.

640
Section 8
Neck
patients with previous infection, tissue planes are oblit-
erated and bleeding may be more pronounced. Keeping
dissection close to the cyst in the midline will avoid
injury to vital structures and ensure that the entire cyst
is removed.
The hyoid bone is then grasped with a tenaculum.
Using sharp dissection with a scalpel or a sharp elevator,
the muscle and soft tissues are dissected from the body
of the hyoid bone. Sharp dissection should not be
carried out superior or inferior to the hyoid bone to
avoid transecting the thyroglossal duct (see Fig. 74-5C).
After skeletonizing the body of the hyoid bone, a small
sharp bone cutter is used to transect the hyoid bone
(see Fig. 74-5D). Forceps are then placed on the hyoid
bone and the bone elevated anteriorly. A curved retrac-
tor (baby Deaver) is next placed transorally such that
the end of the retractor is in the vallecula. Pressure
applied to the retractor displaces the tongue base into
the wound, thus enabling accurate dissection of the
suprahyoid musculature (see Fig. 74-5E). The retrohy-
oid portion of the duct is excised together with an
ellipse of tissue up to the base of the tongue, including
the foramen cecum (see Fig. 74-5F). If the vallecula is
inadvertently entered during the dissection, the defect
should be closed with interrupted nonabsorbable
suture.
Copious irrigation is applied, particularly if the oro-
pharynx has been entered. A Hemovac drain is inserted
1 cm lateral to one edge of the incision, and the wound
is closed in layers by approximating the strap muscles
in the midline and then the subcutaneous tissue. The
skin incision is closed with 6-0 fast-absorbing suture.
An adhesive is then applied, and the incision is
covered with Steri-Strips, followed by a sterile pressure
dressing.
The resected specimen should consist of the cyst,
the midportion of the body of the hyoid bone, and a
generous core of muscle from the base of the tongue
removed en bloc with or without the mucosa of the area
of the foramen cecum (see Fig. 74-5G). Pathologic
evaluation may reveal simple or respiratory columellar
epithelium as the majority of the specimen; however,
squamous epithelium is another predominant pattern,
and 20% of specimens contain thyroid tissue. Waddell
and colleagues33 studied the pathology of 61 patients
who had a neck mass clinically diagnosed as a TGDC.
Their study revealed that although the majority of the
specimens contained thyroglossal duct cyst remnants,
only approximately half could be described as a true
cyst. Normal thyroid tissue is present in approximately
25% of duct remnants. The authors suggest that it
might be more accurate if the term “thyroglossal tract
remnants” were used to cover this whole group of con-
ditions (Table 74-1).
POSTOPERATIVE MANAGEMENT
The Hemovac drain is removed when drainage amounts
to less than 10 mL of serum, which ordinarily occurs
within 24 to 48 hours. The outer dressing is removed,
and the patient is discharged from the hospital. Antibi-
otics are not generally used unless the oral cavity has
been entered or there has been a history of infection
or abscess formation preoperatively. Contamination of
the surgical fi eld by the cyst contents is an indication
for the administration of antibiotics.34 Perioperative
antibiotics are administered for only 24 hours. The
E
F
G
Figure 74-5, cont’d. E, A curved retractor placed in the oral cavity
brings the tongue base into the wound, thereby facilitating dissection
of the thyroglossal duct. F, The retrohyoid portion of the duct is
excised together with a block of muscle (duct) tissue, up to and
including the tongue base as far superior as the foramen cecum.
G, The resected specimen must include the cyst, the midportion
of the body of the hyoid bone, and a core of the muscle of the
tongue base.
Table 74-1
NUMBER OF SPECIMENS IN EACH
HISTOLOGIC GROUP
n
%
Cyst
28
46
Duct (without evidence of a cyst)
24
39
Fibrous tract
5
8
Abscess cavity
2
3
Lymph node
1
2
Epidermoid cyst
1
2
Reprinted with permission from Waddell A, Saleh H, Robert-
son N, et al: Thyroglossal duct remnants. J Laryngol Otol 114:128-
129, 2000.

Chapter 74
Thyroglossal Duct Cyst
641
patients in our series and others34 were generally dis-
charged on the fi rst postoperative day.
COMPLICATIONS
Complications are unusual and may consist of postop-
erative hematoma, seroma, or wound infection. Hema-
toma is treated by returning the patient to the operating
room to evacuate the hematoma and ensure hemosta-
sis. Airway distress has not been encountered.
Hoffman and Schuster studied the results of 90
patients treated at the Children’s Hospital in Boston.5
The authors concluded that the best opportunity for
curative excision is at the initial surgery. Previous inad-
equate or unsuccessful excision serves as a major risk
factor for recurrence. This was refl ected in the 30%
recurrence rate after radical re-excision in patients
referred to Children’s Hospital of Boston for further
management of recurrence, which contrasted with the
recurrence rate of 6.2% in patients undergoing primary
excision by the authors. The authors’ second conclu-
sion was that there does not seem to be any factual data
regarding the absolute incidence of a TGDC traversing
the central portion of the bone. Although the Sistrunk
procedure included the hyoid bone because of embryo-
logic evidence that the duct traversed the hyoid bone,
this may not necessarily be so. Hoffman and Schuster
reported that dissection of soft tissue above the hyoid
bone (Fig. 74-6) is important because of the presence
of accessory ducts and diverticula from the main duct
and pharyngeal mucosa. They suggest wide dissection
of a generous core of muscle between the superior
aspect of the hyoid bone and the base of the tongue.
Variability in the anatomy of the duct was noted in 7.8%
of their 90 patients. They also pointed out that the best
management for recurrent disease is wide secondary
excision with removal of an additional portion of the
hyoid bone or suprahyoid soft tissue as appropriate.
Ducic and colleagues35 indicated that when a branched
TGDC occurs, residual tracts can be left behind while
removing the main tract. Multicystic tracts on histology
were more commonly noted in patients with recurrent
TGDCs. All recurrences were managed successfully by
wider excision. They also found a correlation between
recurrence after the Sistrunk procedure and a history
of recent (6 month) infection of the cyst. Arborization
of the TGDC at the level of the hyoid bone occurred at
a much higher rate in patients who failed a Sistrunk
procedure than in the group that was cured by a Sistrunk
procedure.
Patients with recurring TGDCs have recurrent
swelling and tenderness and discoloration of the skin
in the area of the previously operated TGDC (Fig. 74-7).
Alternatively, these patients may have a cutaneous tract
with drainage. It may not necessarily be in the midline
but may be in another area such as the submental or
submandibular space. An elliptical excision of the skin
surrounding the fi stula tract is then required, followed
by dissection carried from the fi stula to the area of the
hyoid bone. Our experience is that patients with a
recurrent TGDC have not usually had the body of the
hyoid bone removed. In cases in which the cyst recurs
B
C
A
D
D
B
Figure 74-6. Longitudinal section through the thyroglossal duct
demonstrating the tract (A), as well as multiple diverticula (B). Also
seen are serous mucous glands (C) well away from main duct and
adjacent to striated musculature (D) that was taken along with duct.
(Reprinted with permission from Hoffman MA, Schuster SR: Thyroglossal
duct remnants in infants and children: Reevaluation of histopathology and
methods for resection. Ann Otol Rhinol Laryngol 97:484, 1988.)
after the hyoid bone has been already excised, a core
of tissue, as previously described, is removed up to and
including the base of the tongue to incorporate multi-
ple tracts.
PEARLS
• Preoperative ultrasonography provides valuable
information regarding whether the thyroid gland is
present when a TGDC is found. This procedure is
particularly recommended in children because it
spares them exposure to radiation.
• Removal of the TGDC, the midportion of hyoid
bone, and a portion of the base of the tongue
(Sistrunk procedure) remains the procedure of
choice because of the low rate of complications or
recurrence.
• Cancer arising in a TGDC is often an unexpected
fi nding when a TGDC is removed. The presence of
calcifi cations on preoperative scanning is suggestive
but not diagnostic of cancer.
• A 131I study should be carried out when the
diagnosis of cancer in the TGDC is made
pathologically. If no abnormalities are noted in the
thyroid gland, no further surgery is indicated.

642
Section 8
Neck
A
B
Figure 74-7. A and B, Recurrent thyroglossal duct cysts.
PITFALLS
• Failure to conduct a preoperative evaluation may
result in inadvertent removal of the only functioning
thyroid gland.
• Failure to remove the midportion of the body of the
hyoid bone and suffi cient soft tissue at the base of
the tongue results in a high rate of recurrence of
TGDCs.
• Entering the pharynx during the procedure may
result in postoperative infection.
• Unless the skin incision is placed in the natural skin
crease overlying the TGDC, an unsightly scar may
result.
• Carcinoma may arise in a TGDC, even in children,
so removal of TGDCs should not be delayed.
References
1. Gupta P, Maddalozzo J: Preoperative sonography in presumed
thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg
127:200-202, 2001.
2. Sonnino RE, Spigland N, Laberge JM, et al: Unusual patterns of
congenital neck masses in children. J Pediatr Surg 24:996-969,
1989.
3. Hatada T, Ichii S, Sagayama K, et al: Intrathyroid thyroglossal
duct cyst simulating a thyroid nodule. Tumori 86:250-252,
2000.
4. Roy D, Roy PG, Malik VK, Seenu V: Intrathyroidal thyroglossal
duct cyst presenting as a thyroid nodule. Int J Clin Pract 57:637-
638, 2003.
5. Hoffman MA, Schuster SR: Thyroglossal duct remnants in infants
and children: Reevaluation of histopathology and methods for
resection. Ann Otol Rhinol Laryngol 97:483-486, 1988.
6. Marianowski R, Ait Amer JL, Morisseau-Durand M-P, et al: Risk
factors for thyroglossal duct remnants after Sistrunk procedure
in a pediatric population. Int J Pediatr Otorhinolaryngol 67:19-
23, 2003.
7. Allard RHB: The thyroglossal duct cyst. Head Neck Surg 5:134-
146, 1982.
8. Androulakis M, Johnson JT, Wagner RL: Thyroglossal duct and
second branchial cleft anomalies in adults. Ear Nose Throat J
69:318-322, 1990.
9. Murphy JP, Budd DC: Thyroglossal duct cysts in the elderly.
South Med J 70:1247-1248, 1977.
10. Katz AD, Hachigian M: Thyroglossal duct cysts. Am J Surg 155:741-
744, 1988.
11. Sammarco GJ, McKenna J: Thyroglossal duct cysts in the elderly.
Geriatrics 14:98-101, 1970.
12. Van Der Wal N, Wiener JD, Allard RHB, et al: Thyroglossal duct
cysts in patients over thirty years of age. Int J Oral Maxillofac Surg
16:416-419, 1987.
13. Ducic Y: Thyroglossal duct cysts in the elderly population. Am J
Otolaryngol 23:17-19, 2002.
14. Ashurst APC, White CY: Carcinoma in an aberrant thyroid at the
base of the tongue. JAMA 85:1219-1220, 1925.
15. Rampaul R, Maharaj D, Naraynsingh V, et al: Papillary thyroid
adenocarcinoma arising in a thyroglossal duct remnant following
excision of a thyroglossal cyst: The importance of the Sistrunk
procedure. Int J Clin Pract 53:316-317, 1999.
16. Ayala C, Healy GB, Robson CD, Vargas SO: Psammomatous cal-
cifi cation in association with a benign thyroglossal duct cyst. Arch
Otolaryngol Head Neck Surg 129:241-243, 2003.
17. Glastonbury CM, Davidson HC, Haller JR, Harnsberger HR: The
CT and MR imaging features of carcinoma arising in thyroglosssal
duct remnants. AJNR Am J Neuroradiol 21:770-774, 2000.
18. Lübben B, Alberty J, Lang-Roth R, et al: Thyroglossal duct cyst
causing intralaryngeal obstruction. Otolaryngol Head Neck Surg
125:426-427, 2001.
19. Slotnick D, Som PM, Giebfried J, Biller HF: Thyroglossal duct
cysts that mimic laryngeal masses. Laryngoscope 97:742-745,
1987.
20. Brown EG, Albernaz MS, Emery MT: Thyroglossal duct cyst
causing airway obstruction in an adult. Ear Nose Throat J 75:530-
534, 1996.
21. Tunkel DE, Domenech EE: Radioisotope scanning of the thyroid
gland prior to thyroglossal duct cyst excision. Arch Otolaryngol
Head Neck Surg 124:597-601, 1998.
22. Radkowski D, Arnold J, Healy GB, et al: Thyroglossal duct rem-
nants: Preoperative evaluation and management. Arch Otolaryn-
gol Head Neck Surg 117:1378-1381, 1991.
23. Ahuja AT, King AD, Metreweli C: Sonographic evaluation of
thyroglossal duct cysts in children. Clin Radiol 55:770-774,
2000.
24. Weissman JL: Nonnodal masses of the neck. In Som PM, Curtin
HD (eds): Head and Neck Imaging, 3rd ed. St Louis, Mosby–Year
Book, 1996, pp 794-822.
25. Harnsberger RH: Handbook of Head and Neck Imaging, 2nd ed.
St Louis, Mosby–Year Book, 1995, pp 199-223.
26. King AD, Ahuja AT, Mok CO, Metreweli C: MR imaging of
thyroglossal duct cysts in adults. Clin Radiol 54:304-308, 1999.

Chapter 74
Thyroglossal Duct Cyst
643
27. Yang YJ, Haghir S, Wanamaker JR, Powers CN: Diagnosis of papil-
lary carcinoma in a thyroglossal duct cyst by fi ne-needle aspira-
tion biopsy. Arch Pathol Lab Med 124:139-142, 2000.
28. Astl J, Dušková J, Kraus J, et al: Coincidence of thyroid tumor and
thyroglossal duct remnants. Review of the literature and presenta-
tion of three cases. Tumori 89:314-320, 2003.
29. Patel SG, Escrig M, Shaha AR, et al: Management of well-
differentiated thyroid carcinoma presenting within a thyroglossal
duct cyst. J Surg Oncol 79:134-139, 2002.
30. Schlange H: Uber die Fistula colli congenital. Arch Klin Chir
46:390-392, 1893.
31. Sistrunk WE: The surgical treatment of cysts of the thyroglossal
tract. Ann Surg 71:121-126, 1920.
32. Brereton RJ, Symonds E: Thyroglossal cysts in children. Br J Surg
65:507-508, 1978.
33. Waddell A, Saleh H, Robertson N, et al: Thyroglossal duct rem-
nants. J Laryngol Otol 114:128-129, 2000.
34. Dedivitis RA, Camargo DL, Peixoto GL, et al: Thyroglossal duct:
A review of 55 cases. J Am Coll Surg 194:274-277, 2002.
35. Ducic Y, Chou S, Drkulec J, et al: Recurrent thyroglossal duct
cysts: A clinical and pathologic analysis. Int J Pediatr Otorhino-
laryngol 44:47-50, 1998.

Chapter 75
Branchial Cleft Cysts and Sinuses
Eugene N. Myers
Branchial cleft remnants are diagnosed frequently in
both children and adults. The branchial apparatus is a
transient structure that is present from weeks 4 to 7 of
fetal development.1 The general category of branchial
cleft remnants can be subdivided into cyst, sinus, or
fi stula. Depending on the branchial arch origin, these
anomalies can be manifested as a mass or draining
tract anywhere from the preauricular region to the
supraclavicular fossa, lateral to the anterior midline of
the neck and medial to the sternocleidomastoid (SCM)
muscle.
It is helpful to a surgeon managing branchial cleft
remnants to understand the developmental anatomy of
the branchial arch apparatus.2,3 By understanding the
ontogeny of the branchial apparatus, the surgeon can
more accurately predict the course of the branchial
cleft sinus and anticipate important anatomic relation-
ships. Between the fourth and sixth weeks of gestation,
fi ve paired swellings (arches) appear along the ventro-
lateral aspect of the embryonic head. The fi ve swellings
are each associated with a corresponding internal
pouch; externally, the arches are separated by four
grooves. The internal pouches are lined by endoderm,
the external grooves are lined by ectoderm, and the
arches are composed of mesoderm. Each arch also has
an associated cranial nerve, artery, and cartilaginous
element. During development, these arch components
mature into well-defi ned anatomic structures. Incom-
plete closure of branchial pouches or failure of oblitera-
tion of the branchial grooves explain these anomalies.
The presence of a fi stula or draining sinus tract
often simplifi es the diagnosis. A branchial cleft remnant
can also appear as a smooth, fi rm, nontender mass
anywhere from the preauricular region to the supracla-
vicular fossa. The differential diagnosis of a mass in this
location includes the following conditions:
• Benign infl ammatory cervical lymphadenopathy
• Mycobacterial infection (scrofula)
• Lymphangioma (cystic hygroma)
• Hemangioma
• Dermoid cyst
• Neurofi broma
• Lipoma
• Lymphoma
• Salivary neoplasm (benign or malignant)
• Vascular malformations
• Carotid body tumor
• Metastatic carcinoma
Branchial cleft anomalies can occur at any age with
an equal male-to-female ratio and predilection regard-
ing the site of involvement. A 5-year retrospective review
of a series of 71 patients undergoing surgery for bran-
chial cleft anomalies demonstrated an age range of
birth to 16 years (mean, 4.1 years). Patients with a bran-
chial cleft fi stula were initially seen the earliest, at a
mean age of 3 months. The male-to-female distribution
in this pediatric series was 1:1.4 In a review of our
experience consisting of 59 adult patients with a bran-
chial cleft cyst, there was a mean age of 40 years with a
range of 18 to 83 years and a male-to-female ratio of
1:1.5.5
FIRST BRANCHIAL CLEFT ANOMALIES
The fi rst branchial groove gives rise to the external
auditory canal and lateral tympanic membrane, whereas
the fi rst pharyngeal pouch (tubotympanic recess) gives
rise to the middle ear, mastoid air cells, and eustachian
tube. The derivatives of the mesodermal components
of the fi rst branchial arch include the mandible,
the head of the malleus and incus, and the muscles of
645

646
Section 8
Neck
mastication.6 Periauricular cysts, sinuses, and fi stulas
occur commonly in the pediatric population. They arise
from developmental defects of the fi rst branchial cleft
and fi rst branchial arch.7
Anomalies of fi rst branchial cleft/arch structures
can be classifi ed into aplasia, stenosis, and reduplica-
tion types. Surgical treatment of aplasia/stenosis of the
external auditory canal or ossicular deformities requires
reconstruction of the sound-conducting mechanism
and is discussed in Chapter 111. Our discussion is
limited to surgical treatment of anomalies of the fi rst
branchial arch.
Congenital preauricular sinuses and tags result
from faulty resorption of the fi rst arch hillocks. In the
sixth week of fetal life, six hillocks, three arising from
each of the fi rst and second arch mesoderm, develop
around the opening of the fi rst branchial cleft.8 The
fi rst arch derivatives give rise to the tragus only, whereas
the rest of the auricle arises from the second arch. Pre-
auricular sinuses usually occur anterior to the tragus or
the ascending rim of the helix.9
Preauricular sinuses usually have a history of drain-
age, the site of which is highly suggestive of the diagno-
sis (Fig. 75-1). The timing of surgery is dependent on
the age of the patient and the presence of infection.
Excision should be performed after the infection has
been satisfactorily treated. Indications for excision are
recurrent infection and cosmesis because the majority
of these sinuses are asymptomatic and do not require
treatment.
First branchial arch anomalies are rare and account
for less than 10% of all branchial anomalies.10,11 The
external component (mass or sinus) is always located
superior to the hyoid bone. The tract courses through
the parotid gland and has a variable relationship to the
facial nerve; it lies either superfi cial or deep to the main
trunk or travels between nerve branches.12 If present,
the internal communication opens into the external
auditory canal or middle ear, but association with the
ossicles has also been described.13 Blevins and coau-
thors14 reported four patients with both aural atresia
and duplication anomalies of the external auditory
meatus. Three had nonsyndromic unilateral aural
atresia and periauricular lesions originating from the
fi rst branchial cleft. The other patient had a variant of
Treacher Collins syndrome and was evaluated for a
draining infra-auricular fi stula. Yalçin and colleagues15
reported a case of fi rst branchial cleft sinus with choles-
teatoma and atresia of the external auditory canal.
First branchial cleft remnants may be manifested as
a recurrent infl ammatory mass in the periauricular and
cervical region. They frequently rupture spontaneously
and result in a draining sinus. Because of misdiagnosis,
management may be inadequate, recurrence is common,
and iatrogenic injury to the facial nerve may occur. First
branchial cleft anomalies are often located close to the
parotid gland (Fig. 75-2 and see Fig. 75-8B later). Many
lesions diagnosed as intraparotid cysts may be derived
from the fi rst branchial cleft.16 Alternatively, the pres-
ence of purulent drainage in the external auditory
meatus in the absence of active middle ear disease raises
suspicion of an infected fi rst branchial cleft remnant. If
the cyst had previously been excised, it may be present
in another site or may continue to drain or become
recurrently infected. Computed tomography (CT) can
be helpful in localizing the cyst. Daniel and coworkers17
reviewed 15 patients from the experience of Montreal
Children’s Hospital who had a nonmalignant mass in
the parotid area. They reported that the most common
cause of such masses was fi rst branchial arch anomalies,
followed by lymphangioma and dermoid cyst.
Several authors have attempted to classify fi rst bran-
chial cleft anomalies. Work suggested that branchial
cleft anomalies could be divided according to their
embryologic derivative.18 Type I anomalies consisted of
ectoderm only, whereas type II anomalies consisted of
ectoderm and mesoderm. Several authors have pro-
posed revisions of Work’s classifi cation. Belenky and
Medina base their classifi cation on anatomy rather than
histology.19 The Belenky-Medina classifi cation suggests
that a type I anomaly is a cyst or sinus in the preauricu-
lar area. The sinus tract is lateral or superior to the
facial nerve, parallel to the external auditory canal, and
terminates without an opening in the external auditory
canal. A type II anomaly is a cyst, sinus tract, or fi stulous
tract beginning below the angle of the mandible and
running in an anterosuperior direction. The tract ter-
minates at the junction of the bony and cartilaginous
external auditory meatus, either with or without a direct
communication with the meatus. The tract of type II
anomalies generally lies lateral to the facial nerve,
although some may pass medial to it or actually split
and go on either side of the nerve. Belenky and Medina
report that both type I and type II anomalies contain
ectoderm and mesoderm.19
Belmont and Grundfast evaluated data from 14
patients treated for fi rst branchial cleft anomalies.20
They suggest a unifying concept in which some anoma-
lies are proposed to result from imperfect closure of the
ventral portion of the fi rst branchial cleft and others
Figure 75-1. A preauricular sinus that had previously been inade-
quately excised. It is now manifested as an abscess anterior to the
sinus tract.

Chapter 75
Branchial Cleft Cysts and Sinuses
647
ryngeal and hypoglossal nerves, courses between the
internal and external carotid arteries, and terminates
in the upper part of the neck. Third arch sinuses origi-
nate in the apex of the piriform sinus, pierce the thy-
rohyoid membrane, travel inferior and posterior to the
glossopharyngeal nerve and superior to the hypoglossal
nerve, and course posterior to the internal carotid
artery to terminate in the neck. This anomaly is also
closely related to the thyroid gland, which when
infl amed, may cause thyroiditis. Cysts of both the
second and the third arches are usually located at the
anterior border of the SCM muscle at the junction of
the middle and anterior aspect. Occasionally, a second
branchial cleft cyst is found in the posterior triangle
(Fig. 75-4).
We recommend complete surgical excision of
second or third branchial cleft remnants when the cyst
is not infl amed. Preoperative antibiotics, high-
resolution CT, fi ne-needle aspiration, barium swallow
esophagography, and contrast fi stulography, alone or
in combination, can be used for the preoperative evalu-
ation of patients with second and third branchial cleft
remnants. An abscess in the neck located within or sur-
rounding the thyroid gland should alert the physician
Figure 75-2. First branchial cleft sinus with a history of continuous
drainage.
from defective canalization of the dorsal portion of the
fi rst branchial cleft. Patients with these latter anomalies
actually have a duplication of the external auditory
meatus. The Belmont-Grundfast model may provide
insight into the derivation of fi rst branchial cleft anom-
alies. Nevertheless, the clinical issue remains unre-
solved. Some fi rst branchial cleft anomalies clearly have
a sinus tract or fi stula. Cysts are encountered twice as
frequently as either sinuses or fi stulas.10
There does not currently exist an accurate and
effective way for the clinician to determine the relation-
ship of the sinus tract or fi stula to the facial nerve
before surgery. In their series of 10 patients operated
on for fi rst branchial cleft anomalies, Solares and associ-
ates21 reported that seven of the tracts were found deep
to the facial nerve (Fig. 75-3), two were lateral to the
facial nerve, and one was found between branches of
the facial nerve. D’Souza and colleagues22 analyzed a
series of 158 patients and found that fi stulas were more
likely than sinus tracts to be deep to the facial nerve.
Lesions with openings in the external auditory meatus
are associated with a tract superfi cial to the facial nerve.
Accordingly, all patients with fi rst branchial cleft anom-
alies should be counseled about the need for dissection
of the facial nerve during removal of these cysts. Only
surgeons expert in facial nerve dissection should under-
take removal of fi rst branchial cleft anomalies.
SECOND AND THIRD BRANCHIAL
CLEFT ANOMALIES
The vast majority (>90%) of branchial cleft anomalies
originate from the second branchial arch apparatus.
Clinically, the rarely encountered remnant of the third
branchial arch apparatus behaves like the remnant of
the second branchial arch apparatus. There are differ-
ences in their internal openings and anatomic course,
however. The second arch tract originates in the tonsil
fossa, travels superior and lateral to both the glossopha-
Figure 75-3. A fi rst branchial cleft cyst with the tract going deep to
the main trunk of the facial nerve and connecting with the external
auditory meatus.
Figure 75-4. A 15-year-old boy with an atypical manifestation of a
second branchial cleft cyst in the posterior triangle.

648
Section 8
Neck
to the possibility of acute suppurative thyroiditis or a
piriform sinus fi stula with a third or fourth branchial
cleft anomaly.23 A neck abscess is typical of infection of
a third branchial arch cyst, probably via the piriform
fi stula. If this tract is not recognized and removed,
recurrence of the abscess can be expected. The authors
describe the technique of a non–contrast-enhanced CT
with barium swallow. They emphasize that this was not
done as a diagnostic modality but as a tool to better
delineate the tract and its relationship to surrounding
structures, which will aid the surgeon in complete extir-
pation of the tract.
In the setting of a recurrent fi stula or infection in
the neck, contrast esophagography and endoscopy can
be used to more carefully examine the hypopharynx to
look for an internal opening. A third arch remnant is
diagnosed when an internal opening is identifi ed in the
apex of the piriform sinus. Direct laryngoscopy should
be carried out, and a probe or Fogarty catheter should
be inserted to facilitate dissection of this tract. Kim and
associates24 reported successful use of sclerotherapy for
the treatment of third and fourth branchial cleft cysts.
Trichloroacetic acid was injected into the fi stula via
suspension microlaryngoscopy. No serious complica-
tions were encountered.
Histologic evaluation of branchial cleft remnants
reveals some differences between fi rst and second/third
branchial cleft remnants. First branchial cleft cysts
contain both ectodermal and mesodermal derivatives.
The cysts are lined by keratinized stratifi ed squamous
epithelium with adrenal structures (sweat glands, sali-
vary glands, hair follicles). Mesodermal components,
such as cartilage, may also be identifi ed. Second bran-
chial cleft cysts are lined by stratifi ed squamous epithe-
lium. Within the cyst wall are lymphoid aggregates,
which often contain germinal centers (Fig. 75-5).
Previous attempts at excision may lead to the fi nding
of giant cell foreign body reaction, cholesterol clefts,
and chronic infl ammation with fi brosis.
PATIENT SELECTION
Surgical excision of masses in the preauricular, post-
auricular, or lateral cervical region is performed for
diagnostic and therapeutic purposes. Indications for
removing presumed branchial cleft remnants include
(1) symptomatic recurrent infections, (2) improved
cosmesis, (3) recent increase in size, and (4) obtaining
material for histopathologic evaluation. Preauricular
sinuses are excised only for recurrent infection because
most of them are asymptomatic. The size and location
of a branchial cleft cyst at initial evaluation can vary
(Fig. 75-6; also see Fig. 75-4). Many patients give a
history of an increase in the size of a neck mass associ-
ated with an upper respiratory or sinonasal tract infec-
tion. Occasionally, patients will be seen after unsuccessful
attempts at treatment with antibiotics and incision and
drainage (Fig. 75-7). Excision after adequate treatment
includes complete excision of the entire cyst and tract
to prevent recurrence. This may be diffi cult in the
setting of recent active infection or in a patient who has
previously undergone incomplete surgery in which the
epithelium-lined branchial remnant may be “multifo-
cal” because of prior intervention.
Controversy still surrounds the entity of “branchio-
genic carcinoma,” or carcinoma arising in a branchial
cleft remnant.25 None of the 56 adult patients in our
series who underwent excision of branchial cleft rem-
nants had a carcinoma.5
Cystic metastases to cervical lymph nodes are often
mistaken for second branchial cleft cysts. Thompson
and Heffner26 studied the pathology of 136 cases of
cystic metastasis of squamous cell carcinoma. Sixty-
four percent of the primary cancers were found in the
faucial tonsil or base of the tongue. Many of these pri-
maries in the tonsil are not apparent because they are
small and may be found deep in the tonsil crypts.
Correct diagnosis in these cases is achieved with the use
of fi ne-needle aspiration biopsy, direct laryngoscopy,
and tonsillectomy rather than random biopsy of the
tonsil.
Singh and coauthors25 reviewed the controversy sur-
rounding branchial cleft carcinoma and the criteria for
this diagnosis and added two cases that fi t the criteria.
However, our critical view of this article indicates that
tonsillectomy was not performed and therefore metas-
tasis was not actually ruled out. We believe that squa-
mous cell carcinoma manifested as a cystic mass in the
Figure 75-5. Lymphoid follicles in the wall of a branchial cleft
cyst.
Figure 75-6. Typical manifestation of a type II branchial cleft cyst
in the anterior cervical triangle.

Chapter 75
Branchial Cleft Cysts and Sinuses
649
lateral aspect of the neck represents metastasis to a
lymph node from an occult primary cancer arising in
the tonsil or the base of the tongue, not a primary
cancer arising in a branchial cleft cyst.27 Careful and
complete head and neck examination is required in the
preoperative evaluation of all patients to avoid the
pitfall of removing a “branchial cleft cyst” only to fi nd
squamous cell carcinoma.
The presence of an internal connection, the site of
origin, and the size of the cyst determine the magnitude
of the associated symptoms. A fi stula or a sinus tract may
have intermittent external drainage, such as a fi rst cleft
anomaly extending from the external auditory meatus
down along the anterior border of the SCM and mani-
fested as purulent drainage from the tract or cervical
skin. Most patients have a fi rm, nontender mass, usually
in the anterior cervical triangle anywhere from the pre-
auricular region to the supraclavicular fossa. Larger
cysts can produce dysphagia, dyspnea, and stridor.
Infection can lead to an increase in size, severe pain, or
abscess formation with spontaneous rupture or airway
obstruction.
PREOPERATIVE PLANNING
A branchial cleft remnant can generally be diagnosed
by history and physical examination. When carefully
obtained, the history will almost always reveal the pres-
ence of a mass in the neck with fl uctuation in size and
level of discomfort. Activation of lymphoid aggregates
(see Fig. 75-5) in the cyst wall by concurrent upper
respiratory tract infection is the probable mechanism
of recurrent pain, erythema, and swelling.
Tsai and coworkers28 recently reported the prenatal
diagnosis of a branchial cleft cyst. Because such a cyst
could presumably cause upper airway obstruction at
delivery, early surgical excision is recommended. This
mass was visualized prenatally by three-dimensional
ultrasound, a technique that had not been reported
previously. Tracheal deviation was noted 3 days after
delivery, and a 3-cm mass was excised.
Adults with a lateral cervical mass must be ques-
tioned about risk factors for head and neck squamous
cell carcinoma (e.g., tobacco and alcohol use). In such
patients, careful and complete examination of the
upper aerodigestive tract, including the nasopharynx,
must be performed to identify suspicious mucosal
lesions. Metastases from squamous cell carcinoma,
usually from the tonsil, may mimic branchial cleft
cysts in adults, and thus diligence is necessary in estab-
lishing a diagnosis without removing the metastatic
cancer.29
Congenital lesions in the neck are uncommon
causes of deep neck infection but appear clinically in
the same manner as other types of deep neck infec-
tion.30 The authors noted that when the underlying
cause is a congenital lesion, recurrence is more
common. These recurrences are generally attributed to
initial lack of awareness of the underlying pathology.
The major value of this article is that the authors state
emphatically that the addition of CT scanning to the
initial workup provided early evidence of the true
underlying pathology. This information directs man-
agement of the case.
High-resolution CT may be helpful in determining
the size, depth, and precise location of the surrounding
structures in the neck, particularly the facial nerve. Posi-
tron emission tomography (PET) or PET/CT scanning
is an important diagnostic study that can play a key role
in making the distinction between cystic metastasis to a
cervical lymph node and a second branchial arch cyst
in an adult. If fi ne-needle aspiration biopsy is per-
formed, a branchial cleft cyst may be defi nitively diag-
nosed with the fi nding of epithelial cells and debris
in the cyst fl uid; however, complete evacuation of the
contents of the cyst can make dissection at the time of
surgery much more diffi cult and lead to complications.
Ultrasonography may also be helpful because of the
typical superfi cial nature of cysts.31 Sonomorphologic
fi ndings usually demonstrate a rounded mass that has
uniform low echogenicity and lacks internal septation,
with no acoustic enhancement or enlargement.31,32
A
B
Figure 75-7. A, Patient with an
infected second branchial cleft
cyst treated by incision and drain-
age and insertion of a Penrose
drain. B, Computed tomography
scan of the patient in A.

650
Section 8
Neck
Surgical excision of an acutely infected branchial
cleft cyst is technically diffi cult because of edema and
local infl ammation obscuring tissue planes. Fine-needle
aspiration of infected material is helpful in determining
appropriate antimicrobial sensitivities. In more severe
cases, patients are treated with a 7-day course of appro-
priate high-dose intravenous antibiotics, followed by 4
weeks of oral antibiotics before surgical excision of an
infected branchial cleft remnant. This treatment
program may avoid the need for incision and drainage,
which makes defi nitive surgical excision more complex.
These neck masses may be large enough to cause
asymmetry of the neck, dyspnea, or dysphagia or
dysphonia.
SURGICAL TECHNIQUE
The fundamental surgical principle in treating all bran-
chial cleft remnants is complete surgical excision of the
cyst, sinus tract, and when present, previously dissected
tissues, which may harbor epithelial rests. The critical
concept in operations for removal of a fi rst branchial
groove remnant is identifi cation and preservation of
the facial nerve (Fig. 75-8).
Preauricular Cysts/Sinuses
Excision of preauricular cysts/sinuses is usually carried
out under general anesthesia with the patient supine.
In adults, it would be possible to excise them under
local anesthesia with intravenous sedation. A vertical
elliptical incision (Fig. 75-9) is made and incorporated
into the preauricular skin crease if possible. If there is
a scar from previous surgery, it should be excised with
the sinus tract.
Dissection is carried out along the cartilage of the
helix, and if scarring is present from previous surgery,
a margin of cartilage may be removed. Dissection
around the entire sinus tract is carried deep and includes
the cyst. Dissection should be as deep as the temporalis
fascia to be certain of complete removal.
Concern about injury to the facial nerve may limit
the surgeon’s dissection and thereby lead to inadequate
excision and recurrence. The surface landmark for the
main trunk of the facial nerve is the tragus, so dissection
will be well away from the nerve.
First Branchial Arch Remnants
First branchial cleft remnants are excised under general
anesthesia with the patient supine. The surgeon should
inform the anesthesia team that muscle relaxant medi-
cations are not to be administered. Electrophysiologic
monitoring should be used in patients in whom pre-
vious surgery has been performed or infection has
been present. A parotidectomy incision is outlined in
anticipation of exposing the facial nerve. The incision
begins in a pretragal skinfold and extends inferiorly
around the lobule posterior to the angle of the mandi-
ble and anteriorly 2 cm below the inferior aspect of the
body of the mandible. If the cyst or sinus has previously
been incised, it may be adherent to the overlying skin.
An ellipse of skin should be incorporated into the inci-
sion to remove the sinus tract or the scar from previous
surgery along with the specimen (Fig. 75-10A). The skin
fl ap is elevated superfi cial to the platysma muscle over
the face just anterior to the anterior margin of the
parotid gland. Inferiorly, the anterior border of the
SCM, mastoid tip, and posterior belly of the digastric
muscle are identifi ed. The greater auricular nerve is
identifi ed and transected. In some cases it may be
possible to save the nerve.
The tail of the parotid gland is elevated off the SCM
muscle up to the mastoid tip, and the avascular plane
between the parotid gland and the external auditory
canal is dissected. The posterior belly of the digastric
muscle is then identifi ed deep to the mastoid attach-
ments of the SCM. The cartilaginous external auditory
A
B
Figure 75-8. Two-year-old child with a fi rst branchial groove
remnant. A, Excision of the skin around the opening of the sinus
tract. B, Dissection exposes the facial nerve back to the cartilaginous
external auditory meatus.

Chapter 75
Branchial Cleft Cysts and Sinuses
651
meatus (pointer) is identifi ed. The facial nerve exits the
temporal bone through the stylomastoid foramen,
which is lateral to the styloid and medial to the mastoid
process, along the tympanomastoid suture. The main
trunk is located 10 mm deep and 6 to 8 mm anterior/
inferior to the cartilaginous pointer. Depending on the
course and location of the fi rst branchial cleft remnant,
partial parotidectomy may be required.
Once the main trunk of the facial nerve is identi-
fi ed, dissection is carried anteriorly as far as the bifurca-
tion. Attention can now be turned to the distal portion
of the cyst/sinus. Via sharp dissection, the tract is dis-
sected proximally with a narrow cuff of surrounding
normal tissue. The relationship of the tract to the facial
nerve can then be identifi ed. Previous infection or open
drainage makes dissection in this region diffi cult and
potentially dangerous to the facial nerve. In such cases,
physiologic nerve monitoring should be instituted.
Lacrimal probes and dilators can be used to facilitate
identifi cation of a fi rst branchial cleft fi stula during dis-
section. Frequently, the nerve must be mobilized and
retracted to fully expose and remove the tract (see Fig.
75-10B), which is often encountered deep to the main
trunk of the facial nerve.
The tract is dissected proximal to the external audi-
tory canal. A segment of the external canal cartilage
may need to be resected to encompass the sinus tract
completely (see Fig. 75-10C). If external canal cartilage
or skin is resected, the meatus should be allowed to heal
by secondary intention. Should the tract pass medial to
the tympanic annulus and involve the tympanic mem-
brane, tympanoplasty may be required. The wound is
closed in two layers over 1/8-inch closed suction drains.
Deep tissues are closed with 4-0 or 3-0 chromic suture,
and the skin is closed with a running 6-0 mild chromic
gut stitch and reinforced with Steri-Strips.
Figure 75-9. A vertical elliptical incision is incorporated in the
preauricular skin crease. Dissection is carried deep along the cartilage
of the auricle down to the temporalis muscle, and the cyst is then
excised and the wound closed primarily.
A
B
C
Figure 75-10. A, Patient with a recurrent fi rst arch cyst. Injury to the facial nerve occurred during previous incision and drainage of a post-
auricular abscess. B, The facial nerve must be identifi ed so that when the tract is found deep to the facial nerve, it can be excised. C, Gross
specimen of the branchial cleft cyst and the external auditory meatus.

652
Section 8
Neck
Figure 75-11. The incision is placed in a skin crease.
Figure 75-12. The cyst is separated from the cervical fascia, and
the sternocleidomastoid muscle is retracted laterally.
Isaacson and Martin33 described a modifi cation of
this technique in which a smaller surgical approach was
used than generally advocated. The facial nerve was
localized by electrophysiologic means rather than
superfi cial lobe parotidectomy and identifi cation of the
main trunk of the facial nerve and branches.
Second and Third Branchial Remnants
Second and third cleft remnants are excised under
general anesthesia without neuromuscular blockade to
facilitate identifi cation of motor nerves encountered
along the course of the dissection. The patient is placed
in the supine position with the head extended and
rotated to accentuate the cervical cyst. The line for inci-
sion should be drawn with the patient in the anatomic
position before extension and rotation to avoid distor-
tion. A skin incision is made in the natural major skin
crease near the cyst (Fig. 75-11). If a sinus tract or a
previous incision is present, it is incorporated into the
incision and an ellipse of skin is included and left on
the specimen. The skin, subcutaneous tissue, and pla-
tysma muscle layers are incised. Flaps are elevated supe-
riorly and inferiorly to protect the marginal mandibular
branch of the facial nerve. The external jugular vein
may be ligated, and the greater auricular nerve should
be identifi ed and spared.
The cyst is separated from the superfi cial layer of
the deep cervical fascia investing the SCM by sharp and
blunt dissection (Fig. 75-12). As the SCM muscle is
retracted laterally, the spinal accessory nerve may be
exposed and preserved. The cyst should be gently
retracted to prevent rupture of the cyst and contamina-
tion of the wound.
Sharp scissors dissection is used to take down fascial
attachments and adhesions from the posterior and
medial aspects of the cyst. Blunt dissection with a hemo-
stat or a Kitner (peanut) sponge can be used to separate
the cyst from the carotid sheath and hypoglossal nerve,
which are located deep to the cyst (Fig. 75-13). Partial
decompression by needle aspiration or insertion of a
trocar into the cyst may facilitate removal when the cyst
is large and tense and obscures the view of underlying
components of the carotid sheath.
With the inferior aspect of the cyst mobilized, the
dissection proceeds superiorly along the tract. As dis-
section of the tract ascends over the hypoglossal nerve,
bleeding may be encountered from the lingual venous
plexus. Care must be exercised because indiscriminate
clamping can lead to injury of the hypoglossal or supe-
rior laryngeal nerve at this level. The tract is followed
superiorly as it courses between the internal and exter-
nal carotid arteries either anterior (second arch) or
posterior to the internal carotid artery (third arch)
(Fig. 75-13) and passes deep to the posterior belly of
the digastric to enter the pharynx. If no internal con-
nection is identifi ed, the tract can be ligated and tran-
sected at this level from the external approach. Talaat
has described a pull-through technique for transcervi-
cal exposure and transoral removal of complete second
branchial cleft fi stulas.34
There may be only a sinus rather than an actual
cyst. The tract may be long and thereby prevent com-
plete exposure and delivery of the cyst through a low
cervical incision. In such cases we have found it neces-
sary to make a second incision higher in the neck, in a
skin crease at the level of the hyoid bone. The superior
extent of the fi stula can more easily be dissected through
the superior incision; once it has been transected supe-
riorly, the entire specimen can be delivered via the
inferior incision. This stepladder technique allows com-

Chapter 75
Branchial Cleft Cysts and Sinuses
653
Figure 75-13. Separation of the cyst from the carotid sheath and
dissection of the tract to the tonsil.
plete exposure of the entire branchial cleft remnant
without excessive traction on the skin fl aps (Fig.
75-14).
When faced with a patient who has a history of a
recurrent abscess in the neck, especially if surgery has
previously been performed, the surgeon should con-
sider the presence of a third arch remnant with a piri-
form sinus fi stula. A piriform fi stula can be associated
with either the third or the fourth branchial arch, and
the distinction must be made at surgical exploration.35
Huang and colleagues36 described a 5-week-old patient
with an infected third branchial cleft cyst that
progressed to a retropharyngeal abscess. The lack of
response to high-dose antibiotics and incision and
drainage of the abscess led the surgeon to suspect a
piriform fi stula, which was confi rmed at direct laryngos-
copy. This rare combination of a retropharyngeal
abscess associated with a third branchial remnant has
been reported only twice previously. Diagnosis of a piri-
form sinus fi stula may be made by barium swallow, CT
scan, and direct hypopharyngoscopy. Endoscopic place-
ment of a Fogarty vascular catheter into the sinus tract
helps locate this sinus tract during dissection (Fig.
75-15).37,38
The need for complete excision of these lesions
cannot be overemphasized. Because the history of most
patients with third arch remnants includes a recurrent
abscess in the neck and multiple attempts at extirpa-
tion, recurrence is usually the result of failure to recog-
nize or adequately excise the tract connecting with the
piriform sinus. Scarring and disruption of fascial planes
are other important surgical features. When a third
arch remnant is treated by complete excision, identifi -
cation and preservation of the recurrent laryngeal nerve
is necessary to prevent vocal cord paralysis. Thyroid
lobectomy should also be carried out to preserve the
recurrent laryngeal nerve and completely excise the
cyst, particularly if there is infection or previous surgery
has been performed. An attempt should be made to
preserve the parathyroid glands. After identifi cation
of the recurrent laryngeal nerve, the fi stula tract is
excised and the sinus tract from the piriform sinus is
closed with a pursestring suture and inverted to prevent
recurrence.35,38
If the pharynx has been entered, the wound is copi-
ously irrigated with antibiotics, and intravenous periop-
erative antibiotics are administered. A Hemovac suction
drain is placed in the wound via a separate stab incision,
and the wound is closed in layers. The platysma layer is
closed with inverted interrupted 3-0 chromic suture,
and the skin is closed with a running 6-0 fast-absorbing
mild chromic stitch. The skin closure is reinforced with
Steri-Strips, and a dressing is applied.
Edmonds and coworkers39 also concluded that
complete excision of the cyst, tract, and fi stula is neces-
sary to avoid recurrence. Direct laryngoscopy with
examination of the piriform sinus is advocated before
excision of this suspected branchial cleft anomaly. A
combined lateral approach with simultaneous tele-
scopic illumination of the piriform sinus tract aids in
complete extirpation, especially in recurrent cases.
Cote and Gianoli40 made a valiant effort to explain
that there is actually a fourth branchial arch remnant
with the tract extending into the chest, passing poste-
rior to the aorta on the left and the subclavian artery
on the right, looping back up superior to the hypoglos-
sal nerve, and then descending to an external opening
low in the neck. There are two troubling aspects of their
article that actually further obfuscate the issue. The fi rst
is that their diagram of a fourth arch anomaly does not
really show the tract traversing the area described.
There is also no mention of treatment of this lesion,
which sounds as though it would be necessary to
combine the cervical approach with opening of the
mediastinum and chest to completely excise this
lesion.
Jordan and coauthors41 reported the technique of
endoscopic cauterization of the piriform fi stula for the
treatment of a fourth branchial cleft sinus. They suc-
cessfully treated seven patients with this technique,
thereby avoiding external surgical extirpation. They
point out the actual distinction between third and
fourth branchial arch anomalies and discuss the theo-
retical basis of the embryology to justify the title of the
paper.
POSTOPERATIVE MANAGEMENT
Closed suction drainage is continued until the output
is less than 10 mL per 24 hours, which usually occurs
within the fi rst 48 hours. The pressure dressing is
removed before discharge. The Steri-Strip wound
covering is left in place and removed during the fi rst
postoperative visit in 1 week.
COMPLICATIONS
Wound complications are rare but may include hema-
toma, seroma, and infection. Adequate suction drain-

654
Section 8
Neck
B
A
E
C
D
Figure 75-14. A, A 15-year-old patient with a lifelong history of drainage from a sinus tract in the right side of the neck. B to D, Stepladder
incisions are necessary for removal of the branchial cleft sinus exiting in the inferior aspect of the neck. E, The specimen includes the complete
sinus tract and an ellipse of skin around the opening of the sinus tract in the neck.

Chapter 75
Branchial Cleft Cysts and Sinuses
655
A
B
F
E
C
F
E
C
Figure 75-15. A, A piriform sinus fi stula is noted on a barium swallow esophagogram (arrow). B, Laryngoscopy is carried out to identify the
fi stula. E, esophagus; F, piriform sinus fi stula. C, Through the laryngoscope, a Fogarty catheter is placed in the piriform sinus fi stula (F) to aid
in dissection of the fi stulous tract. C, Fogarty catheter.
age allows coaptation of the skin fl aps and obliteration
of dead space, thereby preventing seroma or fl uid col-
lections from forming. Hematoma is due to technical
error and usually requires a return to the operating
room for re-exploration of the wound, evacuation of
the
hematoma,
and
achievement
of
complete
hemostasis.
Complications associated with fi rst branchial cleft
remnants include hematoma, infection, transient facial
paralysis, facial nerve injury, and recurrence of the
remnant. Every attempt should be made to completely
excise the cyst at the fi rst attempt because the potential
morbidity associated with reoperation in this area is
signifi cant. Untoward events can be prevented by metic-
ulous surgical technique, correct identifi cation of the
facial nerve, and careful attention to hemostasis.
Second/third branchial cleft cysts are closely related
to the carotid sheath and the 9th, 10th, 11th, and 12th
cranial nerves. Fibrosis from previous infection or
surgery can cause the cyst to become adherent to these
structures, thus making dissection more diffi cult and
increasing the chance of injury. Failure to recognize
entry into the pharynx can lead to wound infection and
recurrent fi stulization.
PEARLS
• Intricate knowledge of the embryology of the
branchial cleft system is fundamental for success in
the management of these problems.
• The use of CT scanning and ultrasonography has
improved the accuracy of diagnosis and
management of these problems.
• Direct laryngoscopy, barium swallow
esophagography, and CT should be used for the
diagnosis of patients with a history of recurrent
infection of the neck, particularly on the left side.
Such imaging will help make the diagnosis of third
branchial arch remnants with a piriform fi stula.
• Recurrent infection in the periauricular area,
especially in children, accompanied in some cases
by otorrhea with an intact tympanic membrane
suggests a fi rst branchial arch anomaly.
• CT scanning, intraoperative facial nerve monitoring,
and experience in parotid surgery are necessary in
the management of fi rst branchial arch cysts.

656
Section 8
Neck
16. Triglia JM, Nicollas R, Ducroz V, et al: First branchial cleft anoma-
lies. A study of 39 cases and a review of the literature. Arch Oto-
laryngol Head Neck Surg 124:291-293, 1998.
17. Daniel SJ, Al-Sebeih K, Al-Ghamdi SA, Manoukian JJ: Surgical
management of nonmalignant parotid masses in the pediatric
population: The Montreal Children’s Hospital experience. J Oto-
laryngol 32:51-54, 2003.
18. Work WP: Newer concepts of fi rst branchial cleft anomalies.
Laryngoscope 82:1581-1593, 1972.
19. Belenky WM, Medina JE: First branchial cleft cyst anomalies.
Laryngoscope 90:28-39, 1980.
20. Belmont JR, Grundfast KM: First branchial cleft anomalies. A
unifying concept. Paper presented at the Eastern Section Meeting
of the Triological Society, January 29, 1988, New York.
21. Solares A, Chan J, Koltai PJ: Anatomical variations of the facial
nerve in fi rst branchial cleft anomalies. Arch Otolaryngol Head
Neck Surg 129:351-355, 2003.
22. D’Souza AR, Uppal HS, De R, Zeitoun H: Updating concepts of
fi rst branchial cleft defects: A literature review. Int J Pediatr Oto-
rhinolaryngol 62:103-109, 2002.
23. Stone ME, Thompson Link D, Egelhoff JC, Myer CM III: A new
role for computed tomography in the diagnosis and treatment of
pyriform sinus fi stula. Am J Otolaryngol 21:323-325, 2000.
24. Kim KH, Sung MW, Roh JL, Han MH: Sclerotherapy for congeni-
tal lesions in the head and neck. Otolaryngol Head Neck Surg
131:307-316, 2004.
25. Singh B, Balwally An, Sundaram K, et al: Branchial cleft cyst car-
cinoma: Myth or reality? Ann Otol Rhinol Laryngol 107:519-524,
1998.
26. Thompson LDR, Heffner DK: The clinical importance of cystic
squamous cell carcinomas in the neck. A study of 136 cases.
Cancer 82:944-956, 1998.
27. Gourin CG, Johnson JT: Incidence of unsuspected metastases in
lateral cervical cysts. Laryngoscope 110:1637-1641, 2000.
28. Tsai PY, Chang CH, Chang FM: Prenatal imaging of the fetal
branchial cleft cyst by three-dimensional ultrasound. Prenat
Diagn 23:599-610, 2003.
29. Briggs RD, Pou AM, Schnadig VJ: Cystic metastasis versus bran-
chial cleft carcinoma: A diagnostic challenge. Laryngoscope
112:1010-1014, 2002.
30. Nusbaum AO, Som PM, Rothschild MA, Shugar JMA: Recurrence
of a deep neck infection. Arch Otolaryngol Head Neck Surg
125:1379-1382, 1999.
31. Reynolds JH, Wolinski AP: Sonographic appearance of branchial
cysts. Clin Radiol 48:109-110, 1993.
32. Warren MJ, Spencer K, Nayagam M: Sonographic appearance of
branchial cysts. Clin Radiol 49:359-360, 1994.
33. Isaacson G, Martin WH: First branchial cleft cyst excision with
electrophysiological facial nerve localization. Arch Otolaryngol
Head Neck Surg 126:513-516, 2000.
34. Talaat M: Pull-through branchial fi stulectomy: A technique for
the otolaryngologist. Laryngoscope 101:501-502, 1992.
35. Rosenfeld RM, Biller HF: Fourth branchial pouch sinus: Diagno-
sis and treatment. Otolaryngol Head Neck Surg 105:44-50,
1991.
36. Huang RY, Damrose EJ, Alavi S, et al: Third branchial cleft
anomaly presenting as a retropharyngeal abscess. Int J Pediatr
Otorhinolaryngol 54:167-172, 2000.
37. Liu KKW, van Hasselt A: Pyriform sinus fi stula—the role of endos-
copy in its management. Otolaryngol Head Neck Surg 108:373-
379, 1993.
38. Godin MS, Kearns DB, Pransky SM, et al: Fourth branchial pouch
sinus: Principles of diagnosis and management. Laryngoscope
100:174-178, 1990.
39. Edmonds JL, Girod DA, Woodroof JM, Bruegger DE: Third bran-
chial anomalies. Avoiding recurrences. Arch Otolaryngol Head
Neck Surg 123:438-441, 1997.
40. Cote DN, Gianoli GJ: Fourth branchial cleft cysts. Otolaryngol
Head Neck Surg 114:95-97, 1996.
41. Jordan JA, Graves JE, Manning SC, et al: Endoscopic cauteriza-
tion for treatment of fourth branchial cleft sinuses. Arch Otolar-
yngol Head Neck Surg 124:1021-1024, 1998.
PITFALLS
• Lack of understanding of the embryology of the
branchial cleft system will result in misdiagnosis and
mismanagement of patients with such lesions.
• Not using CT scanning or ultrasound will delay
accurate diagnosis and localization of these lesions.
• Excision of fi rst arch anomalies by a surgeon
inexperienced in parotid surgery puts the facial nerve
at risk.
• First arch anomalies that have previously been
infected or operated on are technically diffi cult
surgical cases. Facial nerve electrophysiologic
monitoring is essential in avoiding injury to multiple
structures in the head and neck.
• The use of CT, PET, and fi ne-needle aspiration
biopsy is advisable to make the distinction between
a second branchial arch anomaly and cystic
metastasis to the cervical lymph nodes.
References
1. Stulner C, Chambers PA, Telfer MR, Corrigan AM: Management
of fi rst branchial cleft anomalies: Report of two cases. Br J Oral
Maxillofac Surg 39:30-33, 2001.
2. Chandler JR, Mitchell B: Branchial cleft cysts, sinuses, and fi stu-
las. Otolaryngol Clin North Am 14:175-186, 1981.
3. Rood SR, Johnson JT, Lipman SP, Myers EN: Diagnosis and Man-
agement of Congenital Head and Neck Masses. Self-Instruction
Package. Alexandria, VA, American Academy of Otolaryn-
gology—Head and Neck Surgery, 1981.
4. Kenealy JF, Torsiglieri AJ, Tom LWC: Branchial cleft anomalies:
A fi ve-year review. Trans Pa Acad Ophthalmol Otolaryngol
42:1022-1025, 1990.
5. Androulakis M, Johnson JT, Wagner RL: Thyroglossal duct and
second branchial cleft anomalies in adults. Ear Nose Throat J
69:318-322, 1990.
6. Karmody CS: Developmental anomalies of the neck. In Bluestone
CD, Stool SE (eds): Pediatric Otolaryngology. Philadelphia, WB
Saunders, 1990, pp 1303-1316.
7. Nofsinger YC, Tom LWC, LaRossa D, et al: Periauricular cysts and
sinuses. Laryngoscope 107:883-887, 1997.
8. Moore K: The Developing Human. The Clinically Oriented
Embryology. Philadelphia, WB Saunders, 1988, pp 170-184.
9. Wood-Jones F, I-Chuan W: The development of the external ear.
J Anat 68:525-533, 1934.
10. Olsen KD, Maragos NE, Weiland LH: First branchial cleft anoma-
lies. Laryngoscope 90:423-436, 1980.
11. Ford GR, Balakrishnan A, Evans JNG, Bailey CM: Branchial
cleft and pouch anomalies. J Laryngol Otol 106:137-143,
1992.
12. May M, D’Angelo AJ: The facial nerve and the branchial cleft:
Surgical challenge. Laryngoscope 99:564-565, 1989.
13. Tom LCW, Kenealy JFX, Torsiglieri AJ: First branchial cleft anom-
alies involving the tympanic membrane and middle ear. Otolar-
yngol Head Neck Surg 105:473-477, 1991.
14. Blevins NH, Byahatti SV, Karmody CS: External auditory canal
duplication anomalies associated with congenital aural atresia. J
Laryngol Otol 117:32-38, 2003.
15. Yalçin S, Karlidag T, Kaygusuz I, Demirbag E: First branchial
cleft sinus presenting with cholesteatoma and external
auditory canal atresia. Int J Pediatr Otorhinolaryngol 67:811-814,
2003.

Chapter 76
Management of Tumors of the
Parapharyngeal Space
Eugene N. Myers and Jonas T. Johnson
The management of patients with tumors of the para-
pharyngeal space (PPS) is a challenging task. The
complex nature of the anatomy of the PPS and the
diversity of its contents gives rise to a wide variety of
tumors. This presents an opportunity for technically
challenging surgery. Surgery of the PPS is a relatively
recent activity in our fi eld, because only since the intro-
duction of the computed tomography (CT) scan has
the PPS been characterized.1 Once the imaging tech-
niques became readily available, surgical techniques
were devised to remove the tumors identifi ed within the
PPS.
ANATOMY
The PPS is described as being an inverted triangle with
its base at the base of the skull and the apex at the hyoid
bone (Fig. 76-1). The lateral boundary is the mandible
and the medial boundary is the buccopharyngeal fascia
and the constrictor muscles of the pharynx. Because
two sides of the PPS are bone, tumors arising in the PPS
expand along the path of least resistance toward the
soft tissue of the pharyngeal wall, displacing the wall
and the tonsil to present as a submucosal mass in the
pharynx.
Advances in imaging have demonstrated the divi-
sion of the PPS into prestyloid and poststyloid compart-
ments (Fig. 76-2). The fascia of the tensor veli palatini
muscle runs through the PPS from the styloid process
to its insertion on the lateral pterygoid plate. This
defi nes the separation between the prestyloid and post-
styloid compartments.1 This information is invaluable
in developing a differential diagnosis and plan of man-
agement of these tumors.
The prestyloid PPS contains the deep lobe of the
parotid gland, adipose tissues, small blood vessels, lym-
phatics, and minor nerves. The poststyloid PPS contains
the carotid sheath and is also traversed by cranial nerves
IX, X, and XII. The cervical sympathetic chain lies pos-
terior to the carotid artery.
The clinical correlation of the imaging studies and
surgical fi ndings has provided information that allows
the clinician to predict the tumor type from the imaging
studies with a high degree of accuracy. The tumors of
the prestyloid PPS are usually salivary gland in origin.
Most of these tumors are pleomorphic adenomas that
arise in the deep lobe of the parotid gland and extend
through the stylomandibular tunnel into the prestyloid
PPS (Fig. 76-3). An accurate CT scan should clearly
demonstrate the tumor arising in the deep lobe of the
parotid gland going through the stylomandibular
tunnel, extending medially, and displacing the para-
pharyngeal structures intraorally. Less frequently sali-
vary gland tumors arise de novo in the prestyloid PPS
(Fig. 76-4).
Tumors arising in the poststyloid PPS are almost
always neurogenic in origin. The most common of
these tumors are paragangliomas (PGL), including the
carotid body tumor and glomus vagale. Neurilemmoma
arising from the vagus nerve or the superior cervical
ganglion may also occur in this area.2 Ganglioneuroma
of the PPS has been reported recently.3
A wide variety of other primary tumors may occur
in the PPS (Table 76-1). Even though the majority of
tumors arising in the PPS are benign (Fig. 76-5), malig-
nant tumors of the PPS are also encountered (Table
76-2). Cancers arising in other sites with metastasis to
the PPS have been reported. Aygenc and colleagues4
reported two cases of papillary adenocarcinoma of the
thyroid gland metastatic to the PPS. The authors
describe the pathway of spread of the tumor to involve
the PPS via the lateral retropharyngeal nodes. This
657

Int. carotid a.
Int. jugular v.
XI
X
IX
VII
XII
Figure 76-1. Diagram of parapharyngeal space. (Reprinted with per-
mission from Carrau RL, Myers EN, Johnson JT: Management of tumors
arising in the parapharyngeal space. Laryngoscope 100:583-589, 1990.)
Prestyloid space
Fascia of tensor veli
palatini
Poststyloid space
Figure 76-2. The fascia of the tensor veli palatini muscle divides
the parapharyngeal space into a prestyloid and a poststyloid
compartment.
A
B
C
Figure 76-3. A, Axial computed
tomography scan of a pleomor-
phic adenoma originating in the
deep lobe of the parotid gland
with extension through the stylo-
mandibular tunnel into the pre-
styloid
parapharyngeal
space
(arrows). B, A diagram of the rela-
tionship of the styloid process, the
stylomandibular ligament, and the
mandible. C, A diagram of a tumor
originating in the deep lobe of the
parotid gland passing through the
stylomandibular tunnel into the
prestyloid parapharyngeal space.

Chapter 76
Management of Tumors of the Parapharyngeal Space
659
Table 76-1
HISTOLOGIC DIAGNOSIS OF TUMORS
REMOVED FROM THE
PARAPHARYNGEAL SPACE
Histology
No. of Tumors
Paraganglioma
69
Pleomorphic adenoma
32
Squamous cell carcinoma
10
Neurilemmoma
7
Salivary duct carcinoma
3
Sarcoma
3
Schwannoma
3
Adenocarcinoma
2
Adenoid cystic carcinoma
2
Carcinoma ex pleomorphic adenoma
2
Lipoma
2
Lymphangioma
2
Lymphoma
2
Meningioma
2
Hemangioma
1
Hemangiopericytoma
1
Leiomyosarcoma
1
Liposarcoma
1
Lymphoepithelial carcinoma
1
Mucoepidermoid carcinoma
1
Myoepithelioma
1
Neurofi broma
1
Oncocytic papillary cystadenoma
1
Thyroid carcinoma
1
Warthin’s tumor
1
From the Department of Otolaryngology, University of
Pittsburgh.
Table 76-2
HISTOLOGIC DIAGNOSIS OF
MALIGNANT TUMORS REMOVED
FROM THE PARAPHARYNGEAL SPACE
Tumor
No. of Patients
Carotid body tumor
2
Neurogenic sarcoma
2
Malignant mixed tumor
1
Adenoid cystic carcinoma
1
Neurofi brosarcoma
1
Leiomyosarcoma
1
Liposarcoma
1
Fibrosarcoma
1
Metastatic cancer of the thyroid
1
Malignant meningioma
21
Lymphoma
1
From the Department of Otolaryngology, University of
Pittsburgh.
Figure 76-4. Computed tomography scan demonstrating a pleo-
morphic adenoma arising de novo in the prestyloid parapharyngeal
space. The tumor displaces fat medially (closed arrow). A fat plane
separates the tumor from the parotid gland (open arrow).
Figure 76-5. Axial computed tomography scan reveals a lipoma
involving the parapharyngeal and retropharyngeal space.

660
Section 8
Neck
pattern of spread is in keeping with Rouvier’s descrip-
tion of lymphatic pathway from the thyroid gland to
retropharyngeal nodes in the PPS.
Chiesa and De Paoli5 reported metastasis to the PPS
from nasopharyngeal cancer. Umeda and associates6
reported metastasis of squamous cell carcinoma of the
maxilla to the PPS. Raut and colleagues7 reported a
case of metastatic breast carcinoma, which presented
as a mass in the PPS 15 years after the primary
presentation.
PATIENT SELECTION
The signs and symptoms associated with tumors that
arise in the PPS are numerous and depend on both the
location within the PPS as well as the histologic type.
The most commonly encountered presentation of
the neoplasm involving the prestyloid PPS is an asymp-
tomatic mass in the lateral wall of the oropharynx with
or without a mass in the parotid or the neck (Fig. 76-6).
Expansion of these tumors may interfere with the
proper fi t of a denture and on occasion may become
symptomatic based on the large size, producing inter-
ference with breathing and swallowing. Submucosal
masses are usually asymptomatic and they are often
found on routine physical examination. The presence
of a mass in the parotid is often associated with the mass
in the oral cavity. The presence of pain or neuropathy
should direct the clinician to suspect a primary or meta-
static cancer.
Patients with a tumor involving the poststyloid PPS
may present with a mass in the neck. Lesions of the
posterior PPS may also present with a neuropathy. For
example, a tumor arising from the vagus nerve may
result in paralysis of the vocal cord with resultant hoarse-
ness and aspiration. A tumor originating in the cervical
sympathetic chain may produce Horner’s syndrome.
PREOPERATIVE EVALUATION
All patients being evaluated for a tumor of the PPS
should undergo a thorough history and physical exami-
nation (Table 76-3). The history should be inclusive,
such as that done with other patients with tumors in the
head and neck and should emphasize the possibility of
cranial nerve neuropathies. In patients suspected of
having PGL, a family history should be sought, particu-
larly in patients with multiple PGLs. The history of pal-
pitation, fl ushing, or diffi cult to control hypertension
also should be sought, and these patients should be
evaluated preoperatively for the presence of a pheo-
chromocytoma.8 Physical examination should include
inspection of the head and neck, and direct or indirect
laryngoscopy to evaluate the motion of the vocal cords
and direct palpation of the tumor both intraorally and
extraorally. We do not advocate fi ne needle aspiration
biopsy or incisional biopsy before surgery.
IMAGING
All patients suspected of a tumor in the PPS should
undergo imaging studies. The distinction between
tumors of the prestyloid and poststyloid space may be
made radiographically based on a clear understanding
of the anatomy in this region. In our department, CT
scan with contrast has been used almost exclusively with
the exception of certain patients when there is suspi-
cion of intracranial extension who benefi t from mag-
netic resonance imaging (MRI) studies.
Figure 76-6. Typical appearance of a tumor of the parapharyngeal
space displacing tonsil and uvula medially (arrow).
Table 76-3
PRESENTING SIGNS AND SYMPTOMS
FROM THE PARAPHARYNGEAL SPACE
Sign/Symptoms
No.
(%)
Neck mass
76
47.5
Hoarseness or vocal cord paralysis
16
10.0
Hearing loss
13
8.1
Oropharyngeal mass
11
6.9
Dysphagia
10
6.3
Pain
9
5.6
Tinnitus
9
5.6
Otalgia/aural fullness
7
4.4
CN XII dysfunction
6
3.8
Dyspnea/postnasal drip
5
3.1
Headache
4
2.5
Facial weakness/paralysis
3
1.9
Dizziness
2
1.3
Trismus
2
1.3
Bleeding
1
0.6
Horner’s syndrome
1
0.6
Sleep apnea
1
0.6
Trigeminal dysesthesia
1
0.6
Weight loss
1
0.6
From the Department of Otolaryngology, University of
Pittsburgh.

Chapter 76
Management of Tumors of the Parapharyngeal Space
661
The distinction between tumors of the prestyloid
and poststyloid space is the most important aspect of the
evaluation in that clinical correlation has very clearly
defi ned what type of tumor the patient has and provides
us with a very clear plan of management based on the
location and histology. In most cases, we use the infor-
mation from imaging studies as a substitute for a biopsy.
Tables 76-4 and 76-5 summarize our observations on the
correlation of imaging studies with surgical fi ndings.8
Recently other types of imaging studies have
emerged. Brink and colleagues9 describe the high
degree of accuracy of FDG-PET scanning in the detec-
tion of adrenal gland malignancies, which are often
associated with carotid body tumors. The authors found
that the sensitivity of FDG-PET in paragangliomas seems
to be slightly inferior to DOPA-PET and MIBG-scintig-
raphy. The authors feel that co-registration or image
fusion of 18F-DOPA-PET or 123I-MIBG with MRI/CT
scan may improve diagnostic accuracy.
Tumors that arise de novo in the PPS independent
of the parotid gland have a fat plane separating it from
the deep lobe of the parotid gland. This is a very impor-
tant point in the differential diagnosis, because the
tumors independent of the parotid gland may be
removed through a cervical approach, whereas tumors
arising in the deep lobe of the parotid gland with exten-
sion into the PPS must be approached through a
parotid-submandibular approach in order to avoid
injury to the facial nerve.
SURGICAL APPROACHES
Management of Tumors of the Prestyloid
Parapharyngeal Space
There are a variety of surgical approaches that may be
used for the management of tumors of the PPS (Table
76-6).
Transoral excision has been advocated for neo-
plasms arising in the prestyloid PPS.10 This technique
does not afford the surgeon enough exposure, thereby
depriving the surgeon of the opportunity to identify the
closely related neurovascular structures or Stensen’s
duct. It may also compromise the wound through con-
tamination by oral secretions or seed the tumor into the
mucosa of the palate. Because of these adverse features
we do not recommend that tumors of the PPS be
removed through the transoral approach.
The prestyloid PPS is ideally approached using the
transcervical submandibular technique (Fig. 76-7). The
skin incision is made in the major transverse skin crease
in the neck and carried down through subcutaneous
tissue and platysma muscle. The mandibular branch of
the facial nerve must be identifi ed and preserved. Iden-
tifi cation of the anterior border of the sternocleidomas-
toid muscle facilitates identifi cation of the posterior
belly of the digastric muscle. The submandibular gland
is then dissected free of the surrounding tissues. The
facial artery is clamped, transected, and doubly ligated
with silk suture. The submandibular gland is then mobi-
lized anteriorly and pedicled on the submaxillary gan-
glion and Wharton’s duct. It is not necessary to remove
the submandibular gland as has been reported by
Malone and colleagues,11 but it is important to retract
the gland anteriorly because this exposure provides
direct access to the apex of the prestyloid PPS. Once
the gland has been mobilized and retracted, the tumor
is identifi ed. Using sharp and blunt dissection, the
surgeon separates the tumor from the surrounding
tissues. Cohen and colleagues12 described specifi c
maneuvers that were used to increase the exposure pro-
vided by the transcervical approach. The authors suggest
that dividing the stylomandibular ligament and ante-
rior dislocation of the mandible can increase exposure
by 50%. The stylomandibular tenotomy was also empha-
sized by Orabi and associates.13 The styloid musculature
and the posterior belly of the digastric muscle may
be removed if necessary, thereby further enhancing
exposure.
Tumors in the prestyloid PPS are usually pleomor-
phic adenomas that do not invade the surrounding soft
tissue. However, to prevent recurrence, every effort
should be made to preserve the capsule of the tumor.
A suction drain is placed in the depths of the wound
and brought out just posterior to the skin incision in
order to collapse the dead space. The wound is then
closed and a pressure dressing applied.
Table 76-4
CORRELATION OF IMAGING STUDIES
AND OPERATIVE FINDINGS IN
TUMORS OF THE PARAPHARYNGEAL
SPACE
Computed Tomography Scan
• Accurately defi ned position of the tumor relative to
the styloid in 96% (43/45) of the cases.
• Correct identifi cation of the origin of salivary gland
tumors (parotid vs. nonparotid) in 88% (14/16) of the
cases.
• Assessment of the tumor vascularity correlated with the
angiographic fi ndings (28/28) as well as with the
surgical fi ndings (45/45).
Table 76-5
CORRELATION OF SURGICAL
SPECIMENS WITH ANGIOGRAPHY
Angiography
• Performed for all vascular tumors
• More specifi c than computed tomography scans for
vascular lesions yielding a correct diagnosis in 93%
(26/28) of the cases
Table 76-6
SURGICAL APPROACHES USED IN
SURGERY OF THE PARAPHARYNGEAL
SPACE
Surgical Approaches
• Transoral
• Transcervical submaxillary
• Transcervical
• Transmandibular
• Transparotid
• Infratemporal fossa

662
Section 8
Neck
D
C
B
E
A
Figure 76-7. A, Tumor of parapharyngeal space—previously biop-
sied. B, Computed tomography scan demonstrating tumor of parapha-
ryngeal space. C, Diagram of transcervical approach to prestyloid
parapharyngeal space. Submandibular gland retracted anteriorly. D,
Tumor seen in prestyloid parapharyngeal space. E, Pleomorphic
adenoma completely excised. (C, Reprinted with permission from Rabuzzi
DD, Johnson JT: Diagnosis and Management of Deep Neck Infections. Wash-
ington, DC, American Academy of Otolaryngology-Head and Neck Surgery
Foundation, 1976.)
CASE REPORT
The parotid-submandibular incision is used in patients
whose tumor arises from the deep lobe of the parotid
gland (Fig. 76-8). This approach was used in a 45-year-
old man who had been treated for sleep apnea and
“heroic snoring” for 2 years before being diagnosed
with a deep lobe parotid tumor with PPS extension.
Physical examination revealed a large mass seen through
the oral cavity that completely occupied the posterior
aspect of the pharynx, shifting the tonsil and the uvula
all the way over to the contralateral tonsil with almost
complete airway obstruction. The patient also had a
large mass in the parotid gland. The MR scan revealed

Chapter 76
Management of Tumors of the Parapharyngeal Space
663
a large mass almost completely occluding the orophar-
ynx seen in the sagittal image, whereas in the axial
image, the tumor was noted to arise from the deep
lobe of the parotid gland and the impression made by
the stylomandibular ligament as the tumor extended
into the PPS could be seen. An extended parotid-
submandibular incision was made, the skin fl aps were
elevated, and the main trunk of the facial nerve was
identifi ed by using the landmarks of the anterior border
of the sternocleidomastoid muscle, the mastoid tip, and
the cartilaginous external auditory meatus. The dissec-
tion was then carried anteriorly along the main truck
of the facial nerve. All of the branches were dissected
free of the capsule of the tumor and mobilized. The
superfi cial lobe was pedicled anteriorly and preserved.
The submandibular gland was then mobilized by ligat-
ing the facial artery and displacing the gland anteriorly.
After the deep lobe of the parotid gland was dissected
free of the mobilized branches of the facial nerve, blunt
D
B
C
A
Figure 76-8. A, Large mass in parapharyngeal space displacing uvula to contralateral tonsil. B, Axial magnetic resonance (MR) scan revealing
a tumor originating in the deep lobe of the parotid gland with massive extension into the parapharyngeal space. The dark line (arrow) refl ects
the impression of the stylomandibular ligament. C, Sagittal MR scan demonstrating almost complete obstruction of airway. D, Large parotid
mass noted. The parotid submandibular incision is outlined.
digital dissection was used to enter the PPS through
the submandibular space. Using this three-dimensional
approach, the mass was removed completely, and under
direct vision one could see crossing this encapsulated
mass was the impression of the stylomandibular liga-
ment. At the end of the procedure, after hemostasis
was obtained and the wound irrigated, the superfi cial
lobe of the parotid gland was then replaced in its
anatomic position in order to ensure that the contour
of the face was preserved. The wound was then
closed in layers over a suction drain and a dressing
applied.
Although the literature is replete with descriptions
of techniques, including mandibulotomy, by which
exposure of the PPS may be improved, we do not feel
that this approach is necessary except perhaps in very
unique circumstances. Mandibulotomy can be carried
out either directly through the body of the mandible or
anteriorly with retraction of the mandible laterally.

664
Section 8
Neck
Teng and associates14 described a subcutaneous man-
dibulotomy that the authors feel affords excellent access
to the PPS without the lip-split, chin-split, and fl oor of
the mouth incisions, which are part of the usual midline
mandibulotomy. They propose the approach as an
intermediate step for extensive PPS tumors that are
inaccessible through the transcervical approach yet do
not require a full labiomandibuloglossotomy for safe
and complete removal.
MANAGEMENT OF TUMORS OF THE
POSTSTYLOID PARAPHARYNGEAL SPACE
Most of the tumors that originate in the poststyloid PPS
are tumors of neural origin. Most of these are PGLs (see
Table 76-1), the most common of which is the carotid
body tumor (CBT). It is usually possible to tell preop-
eratively, by imaging studies, whether these tumors are
in fact CBT, glomus vagale tumors, or schwannomas.
The CT scan with contrast is very helpful in the differ-
ential diagnosis. The CBT is located at the bifurcation
of the carotid body, whereas the glomus vagale tumor,
because of its site of origin from the vagus nerve, arises
posterior to the carotid artery.
On CT scanning, both neurilemomas and CBT
may look vascular. If there is a degree of uncertainty
based on the anatomic site, then angiography can be
the deciding factor in making the diagnosis (Fig. 76-9).
Conventional angiography using the transfemoral artery
approach, in our opinion, remains the most accurate
technique for identifi cation of the tumor and assess-
ment of its vascularity. MR angiography (MRA) scan-
ning has been used, but errors in diagnosis can be
made. We recently had a patient in whom a diagnosis
was made of a CBT by history, physical examination,
and a vascular blush on MR scanning. An MRA was
carried out, which confi rmed this diagnosis. Unfortu-
nately, at the time of surgery, an aneurysm of the inter-
nal carotid artery rather than a CBT was identifi ed. This
mistake could have been avoided had a conventional
angiogram been carried out (Fig. 76-10).15
The Shamblin classifi cation16 of CBT and its rela-
tionship to the carotid artery (Fig. 76-11) has proved to
be very useful in the assessment of CBT. The Shamblin
I and Shamblin II types of tumors are amenable to
surgery by dissecting the tumor off of the carotid artery.
However, the Shamblin III tumors in which the carotid
artery is encased cannot be removed safely by this tech-
G
F
E
Figure 76-8, cont’d. E, Facial nerve dissected free from the deep
lobe of parotid gland. Submandibular gland retracted anteriorly
(arrow). F, Blunt dissection through the submandibular space into the
parapharyngeal space releases the tumor. G, Specimen revealing tumor
originating in deep lobe of parotid gland (left), impression of stylo-
mandibular ligament, and parapharyngeal component of the tumor
(right).

Chapter 76
Management of Tumors of the Parapharyngeal Space
665
B
D
A
C
Hypoglossal n.
Tumor
Vagus n.
Figure 76-9. A, Magnetic resonance scan of a 21-year-old woman with bilateral carotid body tumors (arrows). B, Angiogram of same patient
demonstrates a carotid body tumor. C, The operative fi eld, including tumor. The carotid artery and cranial nerves XI and XII have been identi-
fi ed; vessel loops are placed for safety. D, Dissection is carried along the carotid artery in a subadventitial plane up to the bifurcation of the
artery. The external carotid artery is then ligated.
Figure 76-10. Magnetic resonance angiogram of a mass in the neck
mistakenly diagnosed as a carotid body tumor. Transfemoral angiogra-
phy revealed aneurysm of the internal carotid artery.

666
Section 8
Neck
nique. Not only is the artery encased in the tumor, but
also the tumor actually invades into the muscularis of
the artery and cannot be dissected free. Further dissec-
tion then creates an opening in the wall of the carotid
artery. Patients with Shamblin III tumors should
undergo a complete resection of the artery by a vascular
surgeon with reconstruction using either a vein graft or
a synthetic graft (Fig. 76-12).
There is a subset of PGLs referred to as the familial
form (PGL1). These PGLs are multiple and usually
involve the carotid body so that there may be unilateral
CBT or bilateral CBT with additional PGLs arising from
unnamed arteries in the vicinity. The familial PGL
group, in addition to being multiple, is also more likely
to be malignant and more likely to have an associated
pheochromocytoma.
The familial form of PGL has an autosomal domi-
nant inheritance pattern. Baysal and colleagues in
Science reported the analysis of families carrying the
PGL1 gene, which revealed mutations in the SDHD, a
mitochondrial complex 11 gene in hereditary paragan-
glioma, on chromosome 11q23.17 In this paternal inher-
itance pattern, the father may pass the gene along to
the son who has a 50% chance of having a PGL and
passing it along to successive males. However, it may
also pass to the female, who may develop a tumor but
cannot pass the gene to her offspring because of genetic
imprinting.18 The families of patients who have PGL1
should undergo genetic testing. For patients who do
not have the gene, this is reassuring and no further
testing is required. Patients who test positive should
undergo MRI screening. If the MRI discloses a tumor,
this may be removed. If the MRI is negative, it should
be repeated annually so that if a tumor develops it
may be removed safely. Further information is avail -
able at our website:
paraganglioma/study.html.
INDICATIONS FOR SURGERY
Small tumors that have recently been discovered should
be removed, as should tumors demonstrating growth,
whether accelerated or steady, with or without involve-
ment of the lower cranial nerve. Patients with a CBT
may have this tumor removed safely if it falls into the
Shamblin I or II classifi cation. Patients demonstrating
neuropathy, such as vocal cord paralysis or paralysis of
the tongue, should have the tumor removed. These are
usually Shamblin type III and require resection of the
carotid artery. Patients who are elderly, have severe
comorbidities, refuse surgery, or fail the balloon occlu-
sion test should be considered for observation, includ-
ing yearly CT scans, or radiation therapy.
We have not used preoperative embolization
because the lesions in which the carotid artery is not
encased can be dissected off of the muscularis of the
carotid artery using dissection in the subadventitial
plane. We believe that the preoperative embolization
may induce an intense infl ammatory response that may
lead to obliteration of the subadventitial plane, making
dissection of the tumor dangerous.
Patients diagnosed with any paraganglioma should
be questioned about symptoms related to secretion of
catecholamines, including sudden fl ushing, palpita-
tions, and labile or diffi cult to control hypertension. All
patients who have the preoperative diagnosis suggestive
of paraganglioma should have examination of a 24-
hour urine specimen for catecholamines before surgery.
TYPE I
TYPE II
TYPE III
Sup. laryngeal n.
N.X
XII N.
N. XII
Sup. laryn. n
ECA
ICA
N. X
Figure 76-11. Carotid body para-
gangliomas. Shamblin’s classifi cation
scheme: type I—small and easy to
dissect, type II—medium and more
intimately attached to carotid, and
type III—large with transmural inva-
sion of the wall of the carotid requir-
ing resection and grafting. (Reprinted
with permission from Shamblin WR,
ReMine WH, Sheps SG, et al: Carotid body
tumors. Am J Surg 122:733-739, 1971.)

Chapter 76
Management of Tumors of the Parapharyngeal Space
667
C
B
A
Figure 76-12. A, Patient with a mass in the neck, which has increased
in size over a 10-year period. B, Magnetic resonance imaging demon-
strates a large carotid body tumor with numerous fl ow voids. C, Lateral
view of mass extending to prevertebral fascia.
If a patient is found to have a pheochromocytoma, it
should be removed before removing the paraganglioma
in order to avoid a potentially fatal intraoperative hyper-
tensive crisis. If the abnormal catecholamines are
present but no pheochromocytoma is identifi ed, it must
be assumed that an unusual catecholamine-secreting
PGL is present. The anesthesiologist should be con-
sulted and a program for the management of a poten-
tial hypertensive crisis planned in advance.
SURGICAL TECHNIQUES
Tumors of the poststyloid PPS may be approached
through a cervical incision. The incision is placed in a
natural skinfold in the neck and carried through sub-
cutaneous tissue. The skin fl aps are elevated and the
sternocleidomastoid muscle is identifi ed and retracted.
There is no need to dissect the submandibular triangle
in this approach.
Carotid Body Tumor
Once the sternocleidomastoid muscle has been
retracted, the carotid sheath will be identifi ed. The
jugular vein is then identifi ed and dissected free of the
carotid artery. The vagus and hypoglossal nerves are
also skeletonized (see Fig. 76-9). Arterial loops are
placed around these structures for the purpose of iden-
tifi cation and retraction. The common carotid artery is
then identifi ed, skeletonized, and a Penrose drain is
placed around the artery. There is usually a large venous
plexus that goes approximately halfway down from the
bifurcation to the clavicle. At the point where the
carotid artery is clear of this plexus, subadventitial dis-
section is begun. This is carried superiorly until the
bifurcation of the artery is encountered. At this time
dissection is carried superiorly along the external
carotid artery approximately 1 to 2 cm above the bifur-
cation (Fig. 76-13). The artery is then clamped, tran-

668
Section 8
Neck
retracting gently on the carotid artery and the nerve
in order to develop a plane of dissection between the
carotid artery and the tumor. The tumor, which is
usually fusiform in shape, is identifi ed as dissection is
carried superiorly, gently separating the tumor from
the carotid artery and the surrounding tissues. Once
the dissection is carried superior to the tumor itself, the
nerve can be transected. The tumor takes its origin
from the nerve itself and can be abnormal, even distal
to the tumor itself (Fig. 76-14). After being fully mobi-
lized, the mass is excised, with care taken to include any
abnormal-appearing nerve. Because this creates a high
vagal injury with resultant vocal cord paralysis, aphonia,
and potential for aspiration, we always carry out a type
I thyroplasty intraoperatively to medialize the vocal
cord. This avoids postoperative dysfunction and restores
the patient’s ability to speak and swallow.19
Neurogenic Tumors
The most common neurogenic tumors are the
schwannoma of the vagus nerve and the superior cervi-
cal ganglion. The same incision is used as for PGL to
identify and isolate these tumors. Schwannoma of the
vagus nerve is removed in a manner exactly the same
as that described above with the glomus vagale tumor.
An immediate thyroplasty is also carried out.
In the case of the schwannoma of the superior cer-
vical ganglion, a procedure similar to that described
above isolating the neural and vascular structures is
carried out and then the carotid artery is mobilized and
retracted so that the tumor, which arises deep to the
bifurcation of the carotid artery, can be removed intact.
This procedure invariably results in Horner’s syndrome,
which is unavoidable. These tumors can be localized by
preoperative scanning and identifi ed as a tumor of the
superior cervical ganglion. Patients must be counseled
accordingly with respect to Horner’s syndrome.
COMPLICATIONS
Prestyloid Parapharyngeal Space
The most common complication of dissection of this
space relates to the facial nerve. If the tumor arises from
Figure 76-13. Dissection of carotid body tumor in subadventitial
plane. Note ligation of external carotid artery.
B
A
Figure 76-14. A, Patient with glomus vagale tumor. B, Glomus vagale tumor with obvious intravagal tumor (arrow).
sected, and ligated with silk tie and a suture ligature.
The larger CBTs usually extend deep and go down to
the prevertebral fascia (see Fig. 76-12) and if the exter-
nal carotid artery is not ligated it is very diffi cult to gain
entry for dissection in this deep plane (see Fig. 76-13).
The tumor is then dissected off the internal carotid
artery and removed. Identifi cation and retraction of the
neural structures and the jugular vein usually result in
a very clean, safe, uncomplicated, and relatively blood-
less removal of the tumor.
Glomus Vagale Tumor
The glomus vagale tumor is adjacent to but does not
involve the carotid artery. It is important initially to
identify the carotid artery, skeletonize it, separate it
from the tumor, and place a rubber drain around it for
retraction purposes and to gain control of hemorrhage
in case of an inadvertent injury to the artery. The hypo-
glossal nerve is identifi ed and mobilized off of the
tumor. A small vascular loop is placed around it for
purposes of retraction and identifi cation. The vagus
nerve is then identifi ed in the inferior aspect of the
neck, and dissection of the nerve is carried superiorly

Chapter 76
Management of Tumors of the Parapharyngeal Space
669
an embryonic rest, then no complications should be
encountered. If, however, this is a PPS extension of a
deep lobe parotid tumor, then it is possible that injury
to the facial nerve, either from inaccurate dissection or
traction on the nerve, may occur. Patients who have
weakness or paresis from traction on the facial nerve in
whom the nerve is anatomically intact should expect
return of function within 3 months.12 Proper eye care
is essential for patients with facial nerve injury. In the
immediate postoperative period, a moisture chamber is
used. Patients who are expected to have a prolonged
recovery phase benefi t from insertion of a gold weight
into the upper eyelid.
First Bite Syndrome
First bite syndrome may occur in patients with dissec-
tion of prestyloid PPS tumors.20 This is characterized by
a crampy pain in the parotid region after the fi rst bite
of each meal. The pain lasts a few seconds, improves
with each bite, and is extinguished over the next several
bites. Symptoms are at their worst with the fi rst bite of
food in the meal. There is no really good medical treat-
ment. Surgical treatment requires transmeatal excision
of Jacobson’s plexus on the promontory of the middle
ear.
Poststyloid Parapharyngeal Space
The potential for injury to the carotid artery is mini-
mized by preoperative evaluation to rule out the possi-
bility of encasement of the carotid artery and invasion
of the artery by the tumor. Even very precise dissection
in the subadventitial plane is dangerous and should not
be attempted in this setting.
Inadvertent injury to the hypoglossal in itself is not
severe and requires no reconstruction. Inadvertent
transection of the vagus nerve requires immediate thy-
roplasty. However, if both the hypoglossal and the vagus
nerve are injured and the thyroplasty is not carried out,
the patient will have substantial problems with a weak
voice and aspiration.
References
1. Som PM, Biller HF, Lawson W, et al: Parapharyngeal space
masses: An updated protocol based upon 104 cases. Radiology
153:149-156, 1984.
2. Hamza A, Fagan JJ, Weissman JL, Myers EN: Neurilemomas of
the pharyngeal space. Arch Otolaryngol Head Neck Surg 123:622-
626, 1997.
3. Albonico G, Pellegriono G, Maisano M, Kardon DE: Ganglioneu-
roma of parapharyngeal region. Arch Pathol Lab Med 125:1217-
1218, 2001.
4. Aygenc E, Kaymakci M, Karaca C, Ozdem C: Papillary thyroid
carcinoma metastasis to the parapharyngeal space. Eur Arch Oto-
rhinolaryngol 259:322-324, 2002.
5. Chiesa F, De Paoli F: Distant metastases from nasopharyngeal
cancer. J Otolaryngol 63:214-216, 2001.
6. Umeda M, Minamikawa T, Yokoo S, Komori T: Metastasis of
maxillary carcinoma to the parapharyngeal space: Rationale and
technique for concomitant en bloc parapharyngeal dissection. J
Oral Maxillofac Surg 60:408-413, 2002.
7. Raut V, Sinnathuray AR, McClean G, Brooker D: Metastatic breast
carcinoma in the parapharyngeal space. J Laryngol Otol 115:750-
752, 2001.
8. Myers EN, Johnson JT, Curtin HD: Tumors of the parapharyngeal
space. In Myers EN, Suen JY, Myers JN, Hanna EY (eds): Cancer
of the Head & Neck, 4th ed. Philadelphia, WB Saunders, 2003,
pp 511-530.
9. Brink I, Hoegerle S, Klisch J, Bley TA: Imaging of pheochromo-
cytoma and paraganglioma. Fam Cancer 4:61-68, 2005.
10. Goodwin WJ Jr, Chandler JR: Transoral excision of lateral pha-
ryngeal space tumor presenting intraorally. Laryngoscope 98:266-
269, 1988.
11. Malone JP, Agrawal A, Schuller DE: Safety and effi cacy of trans-
cervical resection of parapharyngeal space neoplasms. Ann Otol
Rhinol Laryngol 110:1093-1098, 2001.
12. Cohen SM, Buckey BB, Netterville JL: Surgical management of
parapharyngeal masses. Head Neck 27:669-675, 2005.
13. Orabi AA, Riad MA, O’Regan MB: Stylomandibular tenotomy in
the transcervical removal of large benign parapharyngeal
tumours. Br J Oral Maxillofac Surg 40:313-316, 2002.
14. Teng MS, Genden EM, Buchbinder D, Urken ML: Subcutaneous
mandibulotomy: A new surgical access for large tumors of the
parapharyngeal space. Laryngoscope 113:1893-1897, 2003.
PEARLS
• Tumors in the prestyloid parapharyngeal space are
usually of salivary gland origin.
• Tumors in the poststyloid parapharyngeal space are
usually neurogenic in origin.
• Modern imaging techniques permit the surgeon to
formulate a plan of management without a
preoperative biopsy.
• Excision of a tumor in the deep lobe of the parotid
gland with extension to the parapharyngeal space
requires that the branches of the facial nerve be
mobilized off of the tumor.
• Intraoperative thyroplasty is used routinely when the
vagus nerve is taken or injured at surgery.
PITFALLS
• Attempting to remove a Shamblin III type of carotid
body tumor using a subadventitial approach will
eventuate in massive bleeding due to invasion of the
wall of the artery by tumor.
• Failure to evaluate for abnormal catecholamines in
patients with paraganglioma (PGL) may result in
intraoperative hypertensive crisis in the presence of a
secreting PGL or pheochromocytoma.
• Failure to preserve the lower cranial nerves in
excision of carotid body tumor will result in
hoarseness and aspiration in the postoperative
period.
• Facial nerve injury may be the result of failure to
recognize that the tumor in the prestyloid
parapharyngeal space may actually be extension of a
tumor in the deep lobe of the parotid gland.
• Transoral biopsy of a tumor of the parapharyngeal
space will result in contamination of the mucosa
and make eventual transcervical resection more
diffi cult.

670
Section 8
Neck
15. Song AY, Myers EN, Gupta N: A case of mistaken identity: Intra-
operative discovery of an extracranial internal carotid artery
aneurysm. Ann Vasc Surg 19:896-899, 2005.
16. Shamblin WR, ReMine WH, Sheps SG, Harrison EG Jr: Carotid
body tumor (chemodectoma): Clinicopathologic analysis of
ninety cases. Am J Surg 122:732-739, 1971.
17. Baysal BE, Ferrell RE, Willett-Brozick JE, et al: Mutations in
SDHD, a mitochondrial complex II gene in hereditary paragan-
glioma. Science 287:848-851, 2000.
18. Baysal BE, Myers EN: Etiopathogenesis and clinical presentation
of carotid body tumors. Microsc Res Tech 59:256-261, 2002.
19. Netterville JL, Jackson CG, Civantos F: Thyroplasty in the func-
tional rehabilitation of neurotologic skull base surgery patients.
Am J Otol 14:460-464, 1993.
20. Chiu AG, Cohen JI, Burningham AR, et al: First bite syndrome:
A complication of surgery involving the parapharyngeal space.
Head Neck 24:996-999, 2002.

Chapter 77
Deep Neck Abscesses
Jonas T. Johnson
Deep neck infection is the term used to describe infection
developing within or spreading into the deep cervical
spaces. Deep neck infection should be distinguished
from infection involving the skin and superfi cial struc-
tures of the neck. An understanding of deep neck infec-
tion requires familiarity with the fascial planes of the
neck, the spaces created by these fascial planes, and the
potential routes by which infection may move between
one fascial space and another.
The structures of the neck are encased in connec-
tive tissue. Condensations of this connective tissue
create fascial planes. The deep neck spaces are in fact
only potential spaces that in normal circumstances
contain adipose tissue, blood vessels, and lymphatics.
Deep neck infection occurs when microorganisms pro-
liferate in these potential spaces.
The most common mechanism by which such infec-
tion occurs is dissemination of bacteria, either hema-
togenously or, more commonly, via lymphatics to the
cervical lymph nodes. When local immunity is inade-
quate to eradicate the bacteria, suppuration of the
lymph node may progress to the development of an
abscess within the space. Although the deep neck spaces
are frequently discussed as discrete entities, it is impor-
tant to recall that the spaces are described by condensa-
tions of fascia. When pressure exceeds the capability of
the fascia to retard spread, the process will spread along
planes of least resistance to involve other anatomic
areas. Deep neck infections may be complicated by
airway obstruction, vascular involvement, thrombosis,
pseudoaneurysm or rupture, fulminating tissue necro-
sis, or sepsis.
PATIENT SELECTION
Patients with deep neck infection almost always have
swelling and pain localized to the involved area. This is
commonly associated with fever and leukocytosis. Airway
compromise may be impending or present, and fulmi-
nating sepsis may be evident. Urgent evaluation and
management are required to reduce morbidity and may
be lifesaving.
Submental-Submandibular Space
Infection in the submandibular space may be due to
obstruction of the submandibular duct. Submental
infection is most commonly odontogenic and is typi-
cally ascribed to periapical infections of the fi rst molar.
Abscesses involving the submental space characteristi-
cally begin either superior or inferior to the mylohyoid
muscle (Fig. 77-1). Infection superior to the mylohyoid
muscle produces erythema and edema of the anterior
fl oor of the mouth with elevation of the tongue, dysar-
thria, diffi culty handling oral secretions, and drool -
ing (Fig. 77-2). Progression of infection of the fl oor
of mouth may lead to retrograde displacement of
the tongue (Ludwig’s angina) and, ultimately, airway
compromise. Fulminant Ludwig’s angina may require
tracheotomy to establish an airway before surgical inter-
vention because endotracheal intubation may be
impossible.
Infection inferior to the mylohyoid muscular sling
may come from or extend to involve the submandibular
triangle and gland. Submandibular swelling and pain
are the hallmarks of this condition. Palpable fl uctuance
may develop, although this is ordinarily a rather late
sign of infection, and surgical intervention may be indi-
cated before frank fl uctuance is apparent.
Parapharyngeal Space
Infection of the parapharyngeal space is usually second-
ary to infection in the tonsils or dental apparatus,
although a discrete primary focus of infection may not
be identifi able. Initial symptoms include trismus, pain,
dysphagia, and a stiff neck. A mass effect may produce
a muffl ed “hot potato” voice.
The parapharyngeal space describes the potential
deep cervical space anterior to the carotid sheath,
671

672
Section 8
Neck
medial to the pterygoid musculature, and lateral to the
pharyngeal wall and tonsil. Its base is at the skull base;
its apex is at the hyoid bone. A parapharyngeal space
abscess produces trismus with medial displacement of
the tonsil and lateral pharyngeal wall (Fig. 77-3). This
condition may be diffi cult to distinguish from periton-
sillar abscess, although infection of the parapharyngeal
space is almost always accompanied by brawny indura-
tion of the neck with limitation of cervical motion (Fig.
77-4). These cervical features are not characteristic of
peritonsillar abscess (Fig. 77-5). Fluctuance rarely devel-
ops in patients with a parapharyngeal space abscess
because the space is covered by the bulky sternocleido-
mastoid muscle. Accordingly, the surgeon should not
wait for the development of fl uctuance before initiating
surgical intervention.
Retropharyngeal Space
The retropharyngeal lymphatics drain the sinonasal
tract and nasopharynx; hence, rhinosinusitis is often
considered to be the initiating event. Symptoms include
pain, dysphagia, dysarthria, and a stiff neck. In fact,
irritation of the prevertebral fascia may cause meningis-
mus that mimics meningitis.
The retropharyngeal space is a potential space pos-
terior to the pharyngeal wall and anterior to the alar
component of the prevertebral fascia. This space is clas-
sically described as having a midline raphe, although
infection with suffi cient tissue oncotic pressure may
Figure 77-1. The mylohyoid sling divides the submental space into
two relatively independent sites. The plane of this schematic is
depicted in the inset.
Figure 77-2. This patient had an odontogenic sublingual infection
with tongue protrusion.
Figure 77-3. An abscess in the parapharyngeal space is character-
ized by its location and by the presence of a fl uid-fi lled cavity sur-
rounded by a thick-walled cyst.
Figure 77-4. A child with the characteristic swelling and neck posi-
tioning associated with a parapharyngeal abscess.

Chapter 77
Deep Neck Abscesses
673
cross the midline. The retropharyngeal space is limited
laterally by the carotid sheaths. Free communication
with the parapharyngeal spaces may ensue if tissue pres-
sure is suffi cient. A retropharyngeal space abscess is
characterized by anterior displacement of the posterior
pharyngeal wall, dysphagia, and some voice alteration
described as a muffl ed or “hot potato” voice that is
refl ective of a space-occupying lesion in the oropharynx
or hypopharynx. The retropharyngeal space extends
from the skull base superiorly to the midthorax at
approximately the level of the tracheal bifurcation.
Therefore, a retropharyngeal abscess may “point” into
the mediastinum.
Retropharyngeal infection may be demonstrated
on a lateral neck radiograph. The normal depth of the
retropharyngeal soft tissue overlying C2 averages 4 mm.
Soft tissue greater than 7 mm thick is pathologic in both
children and adults. A rule of thumb is that the retro-
pharyngeal soft tissues are normally no wider than a
third the width of the body of C2 in adults. In small
children, the width of the soft tissue may be equal to
the width of the body of C2 (Fig. 77-6).
Lower in the neck (C6), the retropharyngeal soft
tissue should be considered abnormal if it is greater
than 14 mm in children younger than 15 years or
greater than 22 mm in adults. Interpretation of soft
tissue thickness is unreliable in infants because of diffi -
culty positioning the child and redundancy of this soft
tissue.
A retropharyngeal space abscess frequently pro-
duces severe dysphagia with meningismus character-
ized by posturing of the cervical musculature as a result
of infl ammation of the anterior paraspinal muscles.
The author’s group has observed patients mistakenly
considered to have meningitis when in fact the neck
stiffness was due to a retropharyngeal abscess.
Prevertebral Space
Infection in the prevertebral space originates almost
solely from osteomyelitis of the spine. Formerly, this
meant tuberculosis, although the author’s group has
observed staphylococcal osteomyelitis, often attribut-
able to ostensibly mild penetrating trauma or a postop-
erative sequela of surgery on the cervical spine.
Figure 77-5. Peritonsillar abscess with medial displacement under
the tonsillar soft tissue. The parapharyngeal fat (arrow) remains rela-
tively unaffected.
A
B
Figure 77-6. A, Lateral soft tissue radio-
graph of the neck demonstrating the normal
thickness of soft tissue overlying the cervical
vertebra. B, Retropharyngeal abscess demon-
strating bulging of the retropharyngeal soft
tissue.

674
Section 8
Neck
The prevertebral space is a potential space that lies
anterior to the spinal column in the midline and is
formed by the alar fascia anteriorly and the prevertebral
fascia posteriorly (Fig. 77-7).1 Infection of the preverte-
bral space is usually due to infection that originates in
the spine itself, the classic example being tuberculous
osteomyelitis of the vertebral body. Iatrogenic infection
may follow cervical fusion procedures, in which case the
most common organism is Staphylococcus aureus. The
prevertebral space extends from the skull base superi-
orly to the sacrum inferiorly and may be the conduit of
infection from the neck to the abdomen.
ETIOLOGY OF DEEP NECK INFECTION
Deep neck infection most commonly arises from a site
of active bacterial infection in the upper aerodigestive
tract. An odontogenic source is most common, although
tonsillitis, pharyngitis, and even sinusitis are occasion-
ally identifi ed as the initiating site of infection. None-
theless, it is estimated that the initiating site of infection
is not identifi ed in as many as 50% of deep neck
infections.2,3
An understanding of the bacteriology of deep neck
infection has evolved since the 1970s. Initial reports
indicated that the most commonly involved organisms
were S. aureus and Streptococcus species.1,4 More recently,
an appreciation of the importance of anaerobic bacte-
ria in the development of deep neck infection has
evolved (inasmuch as more than 90% of the fl ora of the
oropharynx are anaerobic bacteria, one would expect
this to be the case, especially in odontogenic deep neck
infection).
One study reported that S. aureus was the predomi-
nant organism isolated in children younger than 1 year.
Older children were most commonly infected with
group A Streptococcus.5 Recent reports indicate an
increase in the incidence of methicillin-resistant
S.
aureus
in
community-acquired
staphylococcal
infections.
Infection in the deep neck spaces is occasionally
due to trauma. For instance, blunt trauma to the ante-
rior aspect of the neck may result in laceration of the
pharyngeal mucosa and direct inoculation of the deep
tissue spaces with bacteria. Alternatively, patients are
occasionally encountered in whom the mucosa is lacer-
ated by a sharp foreign body such as a fi sh or chicken
bone in the hypopharynx. Iatrogenic deep neck infec-
tion may develop after traumatic endotracheal intu-
bation or endoscopic evaluation. More commonly,
perforation of the cervical or thoracic esophagus leads
to infection of the visceral space or the mediastinum.
Use of the internal jugular vein for the intravenous
administration of illicit narcotics is associated with both
deep neck infection and thrombosis of the internal
jugular vein (Fig. 77-8).6,7
A
B
Figure 77-7. A, Axial schematic of the relationship of the potential
space anterior to the vertebral bodies. The alar fascia separates the
prevertebral space from the retropharyngeal space. B, Sagittal drawing
depicting the relationship between the retropharyngeal and prever-
tebral spaces.
Figure 77-8. Intravenous drug abuse may be associated with septic
thrombophlebitis of the internal jugular vein and deep neck
infection.

Chapter 77
Deep Neck Abscesses
675
PREOPERATIVE EVALUATION
Every patient suspected of having infection in one of
the deep neck spaces should undergo computed tomog-
raphy (CT). This allows the surgeon to localize the site
of the lesion to an appropriate space and determine
whether the infection has progressed from local tissue
sepsis (cellulitis) to suppuration (frank abscess). CT will
clearly demonstrate the site of abscess (Fig. 77-9). A
mass with a low-density center surrounded by a high-
density rim suggests central necrosis and abscess forma-
tion. Conversely, development of an infl ammatory mass
that is homogeneous throughout may indicate that the
infection is still in the cellulitis phase. This is important
inasmuch as cellulitis may respond to intravenous anti-
biotics alone whereas surgical drainage is required for
an abscess. This may be especially true in children.8
All patients should be hydrated, and antibiotics
should be administered intravenously. The antibiotics
chosen should refl ect the most likely microbiology and
should be administered empirically before the results
of Gram stain and sensitivity testing are available. In this
regard it is critical that suspicious sites of infection be
cultured and submitted for Gram stain. Additionally,
fi ne-needle aspiration of abscess cavities may be appro-
priate to obtain tissue for Gram stain, as well as culture
and sensitivity testing before the administration of anti-
biotics. We recommend the administration of an
antibiotic effective against β-lactamase, as well as an
antibiotic effective against anaerobic oral fl ora.
The airway should be carefully monitored. If the
patient is having diffi culty handling secretions, is drool-
ing, or is frankly short of breath, an elective tracheot-
omy should be performed immediately. When an
odontogenic source of infection is identifi ed, consulta-
tion with a dentist may be appropriate. On occasion,
drainage of a periorbital abscess or tooth extraction
may contribute greatly to subsequent control of
infection.
SURGICAL APPROACHES
Patients admitted with deep neck infection should be
carefully monitored for the adequacy of their airway.
Patients with infection involving the parapharyngeal or
retropharyngeal space should usually be in an intensive
care setting, and monitoring should include percutane-
ous oximetry. Antibiotics should be administered intra-
venously. We use broad-spectrum coverage with effi cacy
against gram-positive cocci, as well as anaerobic bacte-
ria. Patients who give a history of intravenous drug
abuse, as well as patients with acquired immunodefi -
ciency syndrome or insulin-dependent diabetics, should
be covered for methicillin-resistant Staphylococcus, in
addition to other gram-negative aerobic organisms such
as Klebsiella.6,7,9 When CT suggests cellulitis, the patient
should be monitored regularly for response to therapy.
Failure to improve is an indication to intervene
surgically.
When a deep neck abscess is diagnosed, it should
be drained. A number of authors have described man-
agement of patients with well-localized deep neck infec-
tion by needle aspiration of the abscess and high-dose
intravenous antibiotics.9-11 Some authors have suggested
the introduction of a large-bore catheter or double-
lumen catheter under CT guidance to ensure proper
placement.12 The catheter is then aspirated regularly or
even irrigated. These techniques require close, careful
patient follow-up. Progression of disease is an indica-
tion to institute more aggressive therapy consisting of
open surgery and drainage. Most investigators acknowl-
edge that patients with airway compromise are not good
candidates for needle aspiration therapy, and the physi-
cian should probably proceed directly to establishing
an airway and incision and drainage under these
circumstances.
The standard of therapy for the management of
deep neck abscess is incision and drainage. The sub-
mandibular space can be approached percutaneously
A
B
Figure 77-9. A, The large cystic
cavity in the parapharyngeal space
(arrow) suggests a parapharyngeal
space abscess. B, Cellulitis in the
parapharyngeal space with early
abscess formation in the masse-
teric space is shown.

676
Section 8
Neck
or through the mouth. The choice of access usually
refl ects the specifi c location of the abscess. Abscesses
that develop superior to the mylohyoid sling may be
adequately drained through the fl oor of the mouth.
Generally, however, an abscess that is posterior and
inferior to the mylohyoid muscle requires a transcervi-
cal incision placed in a submandibular skinfold. Care is
taken to avoid the facial nerve. The abscess is opened
bluntly. Finger dissection helps to fully evacuate all
loculations, after which the wound is copiously irrigated
and a drain inserted. Specimens are always obtained for
Gram stain and sensitivity testing.
Access to the parapharyngeal space should be
obtained percutaneously (Fig. 77-10). Usually, a hori-
zontal incision made in an upper cervical skin crease
offers adequate exposure and results in postoperative
cosmesis. This incision should ordinarily be made at
approximately the level of the carotid bifurcation. The
sternocleidomastoid muscle is then refl ected posteri-
orly. The great vessels are refl ected posteriorly and the
abscess cavity entered. The parapharyngeal space is
most easily approached by passing just anterior to the
posterior belly of the digastric muscle. Ligation of the
facial artery with anterior displacement of the subman-
dibular gland may be required. The abscess cavity is
digitally explored, with care taken to break down all
loculations. The wound is copiously irrigated and a
drain inserted. The parapharyngeal space should not
be drained transorally inasmuch as such drainage does
not allow the surgeon to identify and protect important
neurovascular structures.
Limited, well-localized abscesses that involve the
superior aspect of the retropharyngeal space may be
drained transorally. The risk, of course, is that purulent
debris will be aspirated. Accordingly, we recommend
that patients be intubated and placed in the Trendelen-
burg position. The abscess is incised, explored, drained,
and irrigated. Because it is exceedingly diffi cult to leave
Figure 77-10. Surgical approach to the parapharyngeal space.
a drain in the wound after transoral procedures,
this particular approach is suitable only for small, well-
localized abscesses.
When a retropharyngeal abscess is large and life-
threatening, it should be drained transcutaneously. A
horizontal incision is placed in the cervical skin crease
at approximately the midlevel of the abscess, which in
most circumstances may be estimated to be the region
of the hyoid bone. Skin fl aps are minimally elevated
superiorly and inferiorly. Posterior retraction of the
sternocleidomastoid muscle and the great vessels
exposes the retropharyngeal space, which is explored
digitally with care taken to break down all loculations.
The wound should be copiously irrigated. Drains can
be left in multiple sites in the retropharyngeal space to
ensure proper postoperative drainage.
Most patients requiring incision and drainage of
abscesses of the parapharyngeal or retropharyngeal
space should be carefully considered for tracheotomy.
If airway compromise exists preoperatively, tracheot-
omy should be undertaken. Routine endotracheal intu-
bation may be diffi cult or impossible, and postoperative
swelling may persist for several days and require pro-
longed airway support. The tracheotomy may be
removed promptly when the infectious process has
resolved.
Necrotizing cervical fasciitis is a rarely encountered,
potentially lethal infection caused by polymicrobial
organisms, including gram-positive cocci and anaerobic
bacteria, that synergistically produce acute fulminant
infection with tissue necrosis. Classically, patients with
necrotizing fasciitis have evidence of soft tissue air
because of air-forming organisms.13-18 At the time of
incision and drainage, frank purulent debris is not
encountered. Instead, exploration may reveal foul-
smelling gray-brown tissue fl uid with no localization of
infection. Muscle and fascia may be frankly necrotic.
This is a potentially lethal situation. Incision plus drain-
age is inadequate. The entire area of infection must be
exposed in patients with necrotizing fasciitis. Necrotic
tissue should be débrided and the wound left open.
Drains alone are insuffi cient to control this infection.
Broad-spectrum antibiotics should be administered,
and the patient should be monitored in an intensive
care setting. Urgent initiation of hyperbaric oxygen
therapy may be considered. The patient must be
returned to the operating room for débridement of
progressive necrotic tissue on multiple occasions. The
requirement for repeated débridement is the rule
rather than the exception. The wound cannot be closed
until all necrotic tissue has been eliminated and the
wound is actively granulating with healthy tissue. Cos-
metic considerations should be postponed until all evi-
dence of infection is controlled. Failure to adequately
débride all necrotic tissue and assume vascularized
tissue before wound closure may result in death.
Septic thrombophlebitis of the internal jugular vein
may be heralded by a spiking febrile course. CT can also
identify the thrombosed vein as a characteristic O
caused by contrast material on the wall of the vein and
absence of contrast material within the lumen. Jugular