左前胸壁第四鳃裂畸形1例报道及文献回顾

The fourth branchial cleft deformity on the left anterior chest wall:a case report and literature review

目的探讨特殊位置第四腮裂畸形的临床治疗要点,为临床提供参考。方法对1例发生在左前胸壁并以锁骨下方为瘘口第四腮裂畸形患者的临床资料进行总结并结合文献分析。结果该例患者主诉左侧前胸壁肿物反复肿痛2个月,查体见左侧锁骨下方有一10 mm×10 mm瘘口,瘘口持续流出黄色清亮的液体,向上胸锁关节浅面颈胸交汇处触及一20 mm×20 mm×10 mm的肿物,无波动感,活动度欠佳,按压稍疼痛。影像学检查显示为囊性病变。初步诊断为第四腮裂畸形。于患者锁骨下瘘口痕迹、触及囊肿处注入少量亚甲蓝,设计锁骨上T型切口,翻瓣显露亚甲蓝染色的所有区域及邻近的黏膜下组织,于胸骨上切迹颈阔肌深处找到肿块,并沿其周围切开并切除。病理结果为第四腮裂畸形。术后随访1周及3个月后患者均无不适,无复发。复习相关文献表明,第四腮裂畸形是一种先天性发育性异常,发生率占所有腮裂畸形的1%,常以瘘管、囊肿或窦道存在,解剖位置位于颈根部、锁骨上区,其皮肤开口靠近胸锁乳突肌的内侧下边界,诊断时可通过其解剖位置、影像学检查结合术后病理明确诊断,通常与颈部其他肿物如血管瘤、甲状舌管囊肿等进行鉴别诊断。手术切除是常用治疗手段,近年文献报道经内窥镜定位及内瘘口灼烧对于多次复发的第四腮裂畸形疗效较好,少数可复发感染甚至癌变。结论对特殊位置的第四腮裂畸形进行治疗时,临床医生应充分借助影像学方法明确病变的大小、解剖部位及走行,完整、安全切除病灶,预防病灶复发。

Objective To explore the main points of clinical treatment of fourth branchial cleft deformity in special positions and to provide a reference for clinical practice.Methods The clinical data of one case of a fourth branchial cleft deformity that occurred in the left anterior chest wall with a fistula below the clavicle are summarized and combined with a literature review.Results The patient complained of repeated swelling and pain under the left anterior chest wall for 2 months.A 10 mm×10 mm fistula with yellow clear liquid exudate from the fistula was observed on the left side below the clavicle.A 20 mm×20 mm×10 mm swelling was immediately adjacent at the superficial cervicothoracic junction of the upper sternoclavicular joint,with no fluctuation and poor activity;this swelling produced slight pain upon pressing.Imaging examinations pointed to cystic lesions.The primary diagnosis was a fourth branchial deformity.A small amount of methylene blue was injected into the patient’s subclavian fistula,and a supraclavicular T-shaped incision was made where the cyst contacted the fistula.By turning the flap,all the methylene blue-stained areas and adjacent submucosal tissues were exposed.During the operation,a mass was found on the sternum.The platysma was found deep in the notch,which was incised before excising the surrounding area.The pathological result is the fourth branchial cleft deformity.After 1 week and 3 months of follow-up,the patients had no discomfort and no recurrence.A review of the relevant literature shows that the fourth branchial cleft deformity is a congenital development alabnormality that occurs in 1%of all branchial cleft deformity.It often presents as a fistula,cyst,or sinus tract and is anatomically located at the neck root and supravicular region.The fistula is close to the medial lower boundary of the sternocleidomastoid muscle.The diagnosis is often made based on its anatomical location,imaging examinations and,ultimately,pathology.The differential diagnoses include other cervical swellings,such as hemangioma and a thyroglossal duct cyst.Surgical resection is a commonly used treatment method.In recent years,endoscopic positioning and internal fistula burning have had good curative effects for recurrent fourth branchial cleft deformity,with a small chance of recurrence or cancer.Conclusion Given its unique position,clinicians should make full use of imaging methods to determine the size,anatomical location and course of the lesion when treating the fourth branchial cleft deformity to ensure the complete and safe surgical resection of the lesion and prevent recurrence.