Education And Debate


BMJ 1996; 312 doi: (Published 10 February 1996) Cite this as: BMJ 1996;312:368
  1. Mark Davenport

    Lumps arising in the head and neck constitute an important diagnostic category in children. As neoplasia is such a rare cause of head and neck swellings in this age group, lumps can be broadly divided into those having a congenital origin and those due to inflammatory or infective causes. Some knowledge of the embryological development of the neck is important in understanding how a substantial proportion of these lumps arise. It becomes even more important if these are to be surgically excised—the usual treatment.

    Commonest causes of neck lumps in children by age.

    Branchial cleft apparatus and its derivatives

    The branchial arches are well developed ridges that are visible in the cervical region of the embryo from the fourth to the eighth week of gestation. Each consists of a mesodermal cartilaginous centre, an intervening ectodermal cleft, an internal pouch, and a parent nerve. They are believed to recapitulate gill-like structures (Greek, branchia—gills). Although comparative anatomists can identify six such structures, only the first four are distinct in humans. The mandible, eustachian tube, and some bones of the middle ear are derived from the first branchial arch, while the second arch and its internal pouch form the hyoid bone and the tonsillar fossa respectively.

    Branchial arches in human embryo (left) and usual sites of branchial remnants in child (right).

    Branchial derivatives

    These may take the form of cysts, sinuses, or cartilaginous remnants, and it is possible to identify the relevant branchial arch from the anatomical position. Strangely, although most remnants have usually been present since birth, branchial cysts most commonly present in adolescence or adulthood.

    Preauricular and first branchial remnants—Small sinuses and cartilage remnants just in front of the ear are the commonest finding but are probably not of branchial origin. Such preauricular pits may be blind but occasionally lead to a racemose collection of small cysts or to …

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