0:05

So this was a pace that presents with a mass right here involving the right

0:09

protic gland.

0:10

The thing about this mass is I think some people ended up saying an abscess,

0:14

which is reasonable, but the patient was, um, essentially afebrile.

0:19

So they didn't have any signs and symptoms of inflammatory processes or, or,

0:24

or an infectious process.

0:26

So if you do see a cystic mass like this involving the parotid gland,

0:31

especially in the us so granted,

0:33

if I was in India and I saw something like this and maybe in,

0:37

maybe in Malaysia too,

0:38

then you'd have to think of some type of endemic infections,

0:41

like maybe neuro cystic psychosis. But in general,

0:44

it's kind of rare to have a single isolated cyst like this.

0:47

But the most common congenital lesion that you end up seeing in the

0:52

parot gland in a child is gonna be a first brachial anomaly.

0:57

So I did bring this up.

1:00

So the brachial anomalies is that basically they arise from the brachial

1:05

arches. So you know, there's the first brachial um, arch,

1:09

the second brachial arch, et cetera.

1:11

So the first brachial groove gives rise to the external

1:16

auditory canal. So when you're actually looking at the embryo right here,

1:20

this is the first arch and this is the second arch.

1:22

So this area right here ends up forming the external auditory canal.

1:28

So this is again,

1:29

a schematic illustration of the formation of the external

1:33

auditory canal is here, the middle ear Kathy is here,

1:39

and where this just move this, get it outta my way. Um,

1:44

where the

1:46

couch and the external auditory, uh,

1:50

groove form ends up forming the tympanic membrane.

1:54

So what the first brachial arches is that it is,

1:58

there are two types. There's a type one and there's a type two.

2:02

So the type one,

2:04

they're both felt to be duplications of the first brachial apparatus.

2:09

And a type one is basically an intracarotid cyst.

2:13

And we'll see the type two later.

2:15

This is a small little fistula that forms at the junction of the ex,

2:19

the external laboratory canal at the members and the bony junction.

2:23

And it forms a little fistula right here that extends all the way down and

2:28

typically into the region of the submandibular space. So again,

2:31

these are examples of type one first brachial anomalies.

2:34

You can see basically there's cysts right here.

2:37

So if we go back and then look at this case,

2:41

what we see here is the cyst that's involving the parotid gland in an afebrile

2:45

patient. And that turns out to be a first brachial cleft cyst.

2:50

Um, such this should say a type one first brachial anomaly.

2:54

Now what I did wanna say is that, you know, if you do see pure cyst in adult,

2:59

what I have noticed is that if this ends up,

3:03

let's just say this never presented in the child,

3:05

but it ends up presenting an adult,

3:07

then this could be due to quote unquote a parotid cyst.

3:10

It could be due to a unilateral um, salal. But, um,

3:15

years ago we did this study where we actually correlated, um,

3:20

pathology with first brachial anomalies, excuse me,

3:23

I should say congenital anomalies. And what we found out in adults,

3:27

a certain percentage of these that present with these asymmetric a asymptomatic

3:32

intra paric cysts are actually type one first brachial anomalies.

3:37

So let me stop there and then you can ask any questions you want to on this.

3:42

So in, uh, in it still can be the first anomaly.

3:47

Yes, yes. Type one first anoma. Exactly right.

3:50

So there has to be at least included in the differential diagnosis for purely

3:56

cystic lesions for purely cystic,

3:57

Not only the cystic. Yes. Not only the cystic metastatic lymph node.

4:02

For oral pharyngeal ca

4:04

Uh, it would be unusual to have a inid cystic lymph node

4:10

for oral pharynx.

4:10

So that cystic mass was in an adult in a level two lymph node

4:15

that a hundred percent that then you'd have to consider that. Okay.

4:19

The fact that it's actually within the parotid gland. And that makes, um,

4:22

it very unusual.

4:24

This one initially I thought is a part of the says.

4:28

Mm-hmm. Yeah, yeah. Which is reasonable, which is, I remember I saw your report,

4:32

I think that was very reasonable.

4:34

But I think in the comments when I graded your report, I think I said, well,

4:37

the only thing is that there was no history of it.

4:41

'cause I very rare to see type one brain Q anomaly because 80% will be type

4:46

two.

4:47

No, just the opposite 80% are gonna, well, no, hold on for a second. Now.

4:50

So realize,

4:52

I mean the, for the type two brachial anomaly,

4:55

not the type two first al anomaly,

4:59

Right? I think so just to clear up the, the, the, the, your lexicon,

5:04

there's first brachial anomalies in which

5:07

Or second Yes.

5:07

Type one and type two first, brachial anoma,

5:09

then there's second brachial anomalies.

5:11

And I think what you're saying is that the most common brain anomaly second is a

5:15

second, right? That's correct. That's exactly right. Very good.

5:19

Because for the second itself, there are four types.

5:23

Yes, that's exactly right.

5:24

Con confusing. Yes,

5:26

Exactly right. How did you learn that? Did I, did you, do you remember? I,

5:29

'cause I

5:29

Saw most of,

5:30

I think I saw most of the patient with the second er

5:36

and normally I seen the sinus fistula,

5:40

different types of second er. Yeah. And normally in my practice,

5:44

Yeah. Oh, that's good. Do you see this, do you see the diagram here?

5:47

So this is the four types of second brachial anomalies.

5:52

So you have one,

5:53

the type ones are typically involving the skin and the platysma muscle.

5:57

So this is path proven type one second.

6:00

This was the classic type two second.

6:02

So when you look at the second brachi anomalies,

6:04

the type two is the most common.

6:06

The type three extends between the internal and the external carotid artery,

6:09

and it actually visualizes to the tonsil. So for me,

6:13

the way I remember this is that if they actually do a fistulagram and you see

6:17

the fistula extending all the way to the tonsils,

6:21

and then it's going between the internal and the external carotid artery,

6:24

then that's a type three.

6:25

And the type fours are located deep to the plane of the internal and the

6:29

external carotid artery. So again, it's a little bit more common than,

6:32

than you would expect. So I think a lot of these are sometimes referred to,

6:37

or they may be misclassified as these a para pharyngeal cyst or

6:42

a,

6:43

a consular cyst or a cystic retropharyngeal mass.

6:48

But, uh, just in the back of your mind,

6:50

you have to realize if it's purely cystic and the patient's asymptomatic,

6:55

it actually could be a type four brachial cleft, uh,

6:58

a type four brachial arch anomaly. In fact,

7:01

there was a case about 15 years ago where we saw this and I thought it was gonna

7:06

be like a cystic parotid lymph node, but one of my colleagues say,

7:08

could it be a type four second? And it turned out it was a type four second. So,

7:13

uh, just realized if you have these pure cyst, you know, in,

7:15

in addition to a tonsor cyst, it could be a type four brachial, uh,

7:20

type four second brachial cleft cyst.

7:24

And you might, uh, show us the third and four,

7:28

because it's very hard to differentiate between the two. Yep,

7:31

Sure can. It's actually, you know, it's not that hard. Um,

7:35

and I'll tell you why. Okay. So, so you got the, we'll,

7:40

we'll go over the first, right? So we talked about type one first,

7:43

and I think another case is gonna be at type two first. You got that right?

7:47

Mm-hmm. And then we talked about the second,

7:50

which is predominantly involving the tonsil, right? So you got this here.

7:53

Mm-hmm. The type three are actually more common than you think they are.

7:57

So the type three is associated with the piriform sinus,

8:01

and then it crosses between, um, it,

8:04

it actually crosses posterior to the internal, uh,

8:07

carotid artery and runs between the ninth and the 12th nerve.

8:11

But the key thing here is that it's located in the posterior triangle.

8:16

So the,

8:17

the one here on the left was actually pathologically proven third brachial

8:21

anomaly. It was a third brachial cyst and they,

8:23

they took it out 'cause I thought it was gonna be a metastatic lymph node,

8:26

but this was actually a pathologically proven third brachial anomaly.

8:31

And then the more common appearance is that if you have this little cystic mass

8:34

that's located in the posterior triangle,

8:36

this was actually a pathologically proven third brachial anomaly.

8:40

So the way to think the thirds is that if you see a cyst right here,

8:45

that's tic lesion, that's actually posterior to the,

8:49

the external carotid artery. You know, the number one that you,

8:52

that you think about is gonna be a lymphatic malformation,

8:55

but it is the second most common lesion to involve the posterior triangle.

8:59

So that's the way the third is.

9:03

And the other thing for the third, uh, oh yeah, that's, that's the third.

9:05

So the next one is gonna be the fourth. Now I have to admit, I've seen,

9:11

I have seen a lot of confusion as to what's the, what's a third and a fourth.

9:16

The way that I look at it is that I know that the fourth starts

9:21

at here, at the piriform of sinus, goes up and then comes down, okay,

9:25

that's the embryology of the third.

9:28

The fourth is actually pulled down.

9:31

It's actually tethered down down.

9:34

So the fourth can also pierce a thyroid hyoid membrane.

9:37

And there's some controversy as to the difference be where the fistula is gonna

9:42

be, be between the third and the fourth.

9:44

But in general the fourth is right at the apex. So if it's at the apex,

9:48

they tend to extend more inferiorly.

9:52

So this was a patient of a fourth brachial anomaly because it was involved in

9:56

the apex. And notice,

9:57

here's the piriform sitis here and see this little lesion extending down

10:02

inferiorly.

10:02

And these are the ones that typically present with recurrent thyroiditis or

10:06

recurrent anterior neck masses. And then they can,

10:10

they can continue to extend all the way down into the mediastinum.

10:14

So one more example here. This is the, uh, type one first.

10:19

So this is actually in the Prada gland.

10:22

This is a type two first because we can see this area extending here into the

10:25

extra laboratory canal. These are the four types of second.

10:30

So that's involving the skin. This is the classic type two second,

10:34

this is the type three third, and then this is the type four, uh, excuse me,

10:39

type three second. And this is the type four second path proven here.

10:42

And then this is an example of a third bronchial anomaly.

10:46

Notice how it's involving the posterior triangle and then here's an example of a

10:51

fourth brachial anomaly.

10:53

And notice how it's involving the piriform sinus and presenting with recurrent

10:57

anterior neck masses. So those, the way that I classify them, and I think it's,

11:01

I think that's what most people do. Does that answer your question?

11:06

Yeah, it's very clear explanation. Okay, good. Excellent.

11:11

I think a few days ago I saw a patient with the, looked like a four,

11:15

four ular anomaly with the abscess in near the visitor space.

11:20

It's very unusual. Mm-hmm. Without any foreign body injection.

11:25

Maybe that kind of patient may, may have the foot Brinker anomaly. Right.

11:30

Was it a child or an adult?

11:32

Oh, it's an adult.

11:33

Adult, okay.

11:34

Any uhhuh?

11:36

Yeah, no. Be, um, you know,

11:38

one thing you can do if you're wor if you're concerned about is make sure you do

11:41

the reconstructions. Because sometimes you may not be able to see on the axials,

11:45

but if you did have anterior neck infections, make sure you look at the,

11:49

the coronals. I had a case of that too actually recently,

11:53

and I was sort of raised the possibility of a fourth as well.

11:57

So what,

11:57

so I look in the Corona to look at any communication with the apex or the

12:02

sinus?

12:03

Yeah. Just in case. Sometimes if you look real closely,

12:05

you'll see a little air pocket. If you see something like that,

12:07

that make sure you do your reconstructions.