A: This most likely is a branchial cleft cyst. The embryology of these things is fascinating. During the very first few weeks of development, the human embryo goes through a number of phases which basically reinact evolutionary history, to a point. In the head and neck area rudimentary arches resembling gills form, around 8-10 weeks.. Generally, these go on to form structures in the neck such as the little bones around the voice box, various glands, parts of the ear and much more. In a few people, the process of involution is not complete and these little "gills" persist. They may form a complete tract, with an opening on the skin, winding through neck structures to open again inside the back of the mouth. If the tract closes on one end, then a cyst forms, gradually building up fluid.
There are five of these arches, each with a cleft. Persistent cleft from arches three, four and five, are so rare it's hard to find references. 95 per cent arise from the second cleft, so the odds are that is your grandson's situation. Rare cysts from the first cleft are located right up under the ear lobe.
So what's to be done? Live with it or take it out? Well, these are benign lesions, so indications for removal revolve around symptoms. These can include recurrent infection of the cysts, continuous drainage of the tracts, or just large unsightly lumps. The Mayo clinic doctors have an excellent reputation and I am sure will advise carefully.
Prior to any surgical consideration, accurate diagnosis is very important. These odd lesions pass through parts of the neck packed with vital structures. With today's imaging using CT or MRI and maybe putting dye in the tracts, definition is far more accurate that it was when these were first described in the 1800s.
Surgery here can be tricky and is usually performed by specialized head and neck surgeons. I have seen a couple of these in Cape Breton and they were removed with good results.
Q: I have an aunt in nursing home in Calgary, She's 98 and I visited her last November. She's very bright and still gets around well with a walker. Her right leg is much shorter than her left and when she walks she lurches deeply with every step. It seems that the leg almost gives way entirely, but at the last minute it will bear her weight enough to get the other leg under her. She says she has had three operations on her hip and now has no hip joint at all. Can this be right? How can she walk with no hip?
A: She's probably right on. Although hip operations are quite routine these days, with excellent results, there are a few situations where failure happens. For example, in folks with demineralized weak bone, it may not be possible to get the joint replacement parts anchored well enough. If the original problem was a hip fracture, the bone may have re-fractured, or splintered into hopeless fragments. Perhaps infections occurred.
Whatever the causes, there can be a point reached at which it is just not reasonable to offer any more attempts at reconstruction. The old pieces of prostheses and bits of loose bone are removed and the area is left to heal in as best as it can. There is no hip joint left. In time scar tissue forms, toughens and many of these folks can get around. One hundred years ago this operation, called a "girdlestone" procedure, was done first time around, mainly for pain relief. I recall seeing a patient many years ago, who had a girdlestone procedure done when he was a teenager. He was amazingly mobile.
So scar tissue, while it can be sometimes very annoying, can also be your friend.
Dr. Rex Dunn is the Cape Breton District Health Authority’s vice-president of medicine and chief of staff. He has been a general surgeon in Sydney for 32 years. Send your question to [email protected] or write to Ask the Surgeon, Box SY-RD, PO Box 1500, Sydney, N.S., B1P 6K6. Individual replies are impossible, but your identity will remain entirely confidential.