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20UDK: 616-007.16: 616-089.87
Karnauhov A. T.,
doctor of medical science, professor of surgical dentistry and maxillofacial surgery department
Irkutsk state medical university Alyoshkin I.G.,
candidate of medical science, associate professor Head of surgical dentistry and maxillofacial surgery department
Irkutsk state medical university Makovetskaya E.A.,
candidate of medical science, assistant professor of children dentistry department
Irkutsk state medical university Suchilina M.I.
assistant professor, resident of surgical dentistry and maxillofacial surgery department
Irkutsk state medical university DOI: 10.24411/2520-6990-2019-11240 THE FREQUENCY OF THE OCCURENCE OF CONGENITAL CYSTS AND FISTULAS OF THE MAXILLOFACIAL AREA IN CHILDREN AND THE METHOD OF THEIR SURGICAL
TREATMENT
Abstract
The article contains the frequency of occurrence of congenital cysts and fistulas of the face and neck in children (parotid, lateral and medial), presents the images of them; describes the original method of surgical treatment of lateral fistulas of the neck, developed on the basis of the Ivano-Matreninsky children clinical hospital of Irkutsk.
Key words: children, congenital malformations, cysts, fistulas, maxillofacial area, frequency of occurrence, treatment.
In recent years, there is an increasing of the incidence of the congenital malformations of the maxillofacial area. The most significant causes of this pathology include negative environmental changes (pollution, increased radiation background), the influence of drugs, alcohol, nicotine on fetus, infectious diseases of mother's organism, narcotic drugs, used by her; as well as hormonal changes during embryogenesis, hereditary predisposition, etc. Factors leading to the formation of congenital malformations are called teratogenic.
The impact of teratogenic factors leads to the appearance of congenital cysts and fistulas of the face and neck. They are divided into:
1) cysts and fistulas of the parotid area, external auditory canal and auricle;
2) lateral cysts and fistulas of the face and neck;
3) medial cysts and fistulas of the face and neck.
The first two groups of the pending pathology are
associated with an anomaly of development of the Ist and the IInd pairs of gill arches, in which they don't obliterate, or if their obliteration is partial. Such cysts and fistulas are called branchial (from lat. branchiae — gills).
The third group of congenital cysts and fistulas is caused by non-closure of the thyroglossal duct in the embryonic period, therefore they are called thyroglos-sal.
A congenital cyst is a round formation of elastic consistency, painless on palpation, mobile, has sharp borders; a positive symptom of fluctuation is possible. During life, it can inflame. Inflammation leads to the formation of the fistula, or less commonly, to the abscess of the area in which the cyst localizes.
Congenital fistula can be single-, double-sided, with or without branches, complete (in the presence of external and internal excurrent openings) and incom-
plete (in the presence of one of them). It can appear independently or be the result of suppuration and emptying of the corresponding cyst.
Congenital cysts and fistulas of the face and neck manifest not only in childhood but also in adults not infrequently.
Cysts and fistulas of the parotid area, external auditory canal and auricle
The cyst localizes either in the parotid-chewing area under the parotid salivary gland, or in the retro-mandibular area, behind the gland, near the large branches of the facial nerve.
Fistulas of this area depending on localization are divided into:
1) preauricular — the external opening localizes anteriorly of the auricle curl;
2) the fistula of the retromandibular area — the external opening is between the angle of the jawbone and the front edge of the sternocleidomastoid muscle.
The cyst and fistula are often connected with the cartilaginous part of the external auditory canal. The internal opening of the complete fistula locates here, in an incomplete fistula, its walls are interwoven here.
Lateral cysts and fistulas of the face and neck
The cyst locates in the upper or middle third of the neck and is closely adjacent to its neurovascular bundle, being anterior of the sternocleidomastoid muscle and downwards of the posterior abdomen of the digastric muscle or stylohyoid muscle.
A complete fistula of the lateral surface of the neck uncloses by an external opening on the front edge of the sternocleidomastoid muscle, while its internal opening lies on the upper pole of the palatinal tonsil of the corresponding side. There is only an internal opening in an incomplete fistula, which complicates the diagnosis of this formation, because it manifests by the periodic oc-
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currence of a one-sided tonsillitis. Fistulas of this localization pass between the external and internal carotid arteries.
Medial cysts and fistulas of the face and neck
A thyroglossal cyst is a result of violation of the obliteration of the thyroglossal duct during embryogenesis. It often lies along the midline of the neck between the thyroid cartilage and is soldered to the hyoid bone, therefore it moves upward with the bone during swallowing. Less often, the cyst locates in the root of the tongue and on the diaphragm of the mouth in the form of several cysts, different in volume with a connection with the blind opening of the tongue. In this case, they lift the organ up, making eating, swallowing, speech, sometimes breathing difficult.
Thyroglossal fistulas can be complete — the external opening uncloses on the skin of the neck between the thyroid cartilage and the hyoid bone. Sometimes fistula has a form of double-barreled gun — 2 pinholes on the different levels of the front surface of the neck, and the internal opening in the area of the blind opening of the tongue root.
Incomplete external fistulas are detected in the projections of the hyoid bone and are associated with it. They end blindly in soft tissues and sometimes are soldered to the hyoid bone.
It is worth noting that cysts and fistulas can deviate from the midline of the neck, which should be considered in the differential diagnosis of this pathology.
Diagnosis of congenital cysts and fistulas of the face and neck is based on clinical data, fistulography and cytological examination of the cyst's content in puncture. Fistulography with contrast substances helps to identify the course, length and branches of the fistula. A cytological examination of the content of the cyst determines areas of stratified squamous epithelium with an admixture of lymphoid elements. Ultrasound examination, magnetic resonance imaging, CT scan, less commonly Doppler echography are also used.
Surgical treatment of congenital cysts and fistulas of the face and neck
Cysts and fistulas of the parotid area are removed by making an incision fringing the angle of the j awbone in the retromandibular area, or an incision parallel to the trunks and branches of the facial nerve in the parotid-chewing area. The branches of the facial nerve are thoroughly separated from the pathological formation, a part of the cartilaginous, and sometimes the osseous section of the external auditory canal is excised. The branches of the fistula are also excised. In some cases, subtotal resection of the parotid salivary gland is performed.
Lateral cysts and fistulas are removed, starting the operation with an incision along the front edge of the sternocleidomastoid muscle or along the neck folds. A large neurovascular bundle is carefully separated. After liberation of fistula its pharyngeal opening is ligated, or a purse-string suture is applied.
An incision in medial cysts and fistulas is carried out along the cervical folds, a resection of the hyoid bone is performed together with excision of formation. When the cyst localizes closer to the oral cavity, it is removed by intraoral way. During the liberation of the fistula, cauterization of the blind opening of the root of the tongue is also carried out.
According to various authors, relapse of congenital cysts and fistulas of the face and neck occurs in 1080% of cases. It is necessary to create optimal atrau-matic methods of treating this pathology, which could minimize the risk of its recurrence and get optimal cosmetic results.
In the unit of maxillofacial surgery of the Ivano-Matreninsky children clinical hospital (IMCCH) of Irkutsk 35 children with congenital cysts and fistulas of the maxillofacial area were observed for the period from the April of 2018 to the April of 2019. There were 19 children with medial cysts and fistulas of the neck, 13 — with lateral cysts and fistulas, 2 — with this pathology of parotid-chewing area (Fig. 1, 2, 3, 4, 5). A child with a congenital medial fistula of the nose was entered to the unit for the said period of time (Fig. 6).
Fig. 1. Child T., 9 years old, congenital medial cyst of the neck
Fig. 2. Child R., 7 years old, congenital medial fistula of the neck
Fig. 5. The macroslide of the removed medial cyst (in form of the several cysts) of the neck of the child B.,
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13 years old
Fig. 6. Child S., 8 years old, medial congenital fistula of the nose.
On the basis of the hospital a technique of the surgical treatment of congenital lateral fistulas of the neck was developed. The operation is performed under intubation narcosis. After antiseptic processing of the surgical field, a horizontal incision is made, which fringes the external opening of the fistula. After it, fistulous passage is partially liberated by sharp and blunt paths, and a fishing line or catheter of medical system is inserted into the incision. Next, a second horizontal incision is made, which locates 1.5-2 cm below the edge of the jawbone and fringes its angle. The fistulous passage is again partially liberated to the middle of the neck and separated from the surrounding tissues. For complete excision of the fistulous passage, it is pulled out in the oral cavity from the upper pole of the palatinal tonsil, and the area of its internal opening is burned with iodine, or is bandaged with a purse-string suture (crumbling of the cells of the internal lining of the fistula to prevent relapse).
The advantages of this method of treatment of the pathology are less trauma, faster healing of wound and high aesthetics of the postoperative scar, because the incisions are made along the natural folds of the neck and have a small length.
The technique is not used in the treatment of medial fistulas of the neck due to their small thickness (rupture during the operation makes difficult to find the ripped end of the fistulous passage) and their connection with the hyoid bone (need in resection of the part of the bone). Therefore, medial fistulas on the basis of
IMCCH are excised by standard methodic. Fistulas of the parotid and retromandibular areas are also removed classically.
The presented congenital fistula of the nose (Fig. 6) ended blindly on the back of the nose; for its excision, incision fringed external opening of the fistula and its partial separation were performed. A fishing line was introduced into the formed course, the fistulous passage is completely pulled out after it. Optimum cosmetic results without relapse were obtained.
In conclusion, it is essential to add that congenital cysts and fistulas of the face and neck have a rather high frequency of occurrence. The prevalence of congenital pathology of the maxillofacial area confirms the need of improving existing treatment methods of them to perfect the quality of life of patients with it in childhood and adulthood.
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