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Old 10-01-2011
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Question Neck mass draining clear fluid after exercise

You are viewing at the anterior neck of a 24-year old male medical student. He has reddish spot (in circle) that is in the center of a slightly raised area just anterior to his sternocleidomastoid muscle about one and a half inches superior to his jugular notch. He has had this reddish raised area for as long as he can remember. If you push on it, it feels attached to something that extends superiorly from this location. At times it leaks a little clear fluid after he has been heavily exercising for long periods of time. What do you think this congenital anomaly is?

Neck mass draining clear fluid after exercise-neckpic.jpg
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A. Glossopharyngeal fistula
B. An internal branchial sinus
C. A branchial fistula
D. A hyperactive sebaceous gland
E. Spina bifida occulta
F. Thyroglossal duct cyst
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Old 10-01-2011
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A branchial fistula
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Branchial fistula
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Old 10-04-2011
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EXPLANATION: This congenital anomaly is a branchial fistula. When the pharyngeal pouches persist, they may form connections to the exterior of the neck immediately anterior to the boundary of the sternocleidomastoid muscle. Since this weeps fluid it is most likely a fistula or external cyst (which was not one of the options). An internal branchial sinus (answer b) would only be a blind pouch off the pharynx and have no external connections. The internal opening for this fistula would most likely be within the bed of the palatine fossa (2nd pharyngeal pouch) or further inferiorly within the pharynx if is from the third or lower pharyngeal embryonic pouches. Persistent glossopharyngeal fistula (answer a) (opening of the embryonic glossopharyngeal duct) more rarely makes a connection to the surface ectoderm and like a thyroglossal duct cyst (answer f) would be a midline structure. A hyperactive sebaceous gland (answer d) would not secrete a clear fluid. Spina bifida occulta (answer e) is associated with a tuft of hairy skin over a defect in the posterior arch of the spinal cord.
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Anatomy-, Clinical-Signs, Embryology-, Figures-, Step-1-Questions

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