A cervical fistula is a maldevelopment of the cervical viscera. This is a congenital damage.
What is a cervical fistula?
Cervical fistulas are associated with neck cysts. Medical professionals distinguish between lateral and median cervical fistulas or cervical cysts. While lateral fistulas are expressed in the lateral region of the neck, median neck fistulas develop at the midline of the neck. In addition, there are neck cysts at the gill arch.
Causes
Cervical fistulas or neck cysts are congenital, but in the lateral form often do not become apparent until adulthood. The median cervical fistula is usually located between the hyoid bone and the thyroid gland. It grows from portions of the thyroglossal duct during embryonic development and does not regress. If the thyroid gland anlage descends from the base of the tongue, which develops later, in the caudal direction, this leads to the formation of a connection in the direction of the pharynx. This is the ductus thyreoglossus. If this duct cannot close completely, this results in the retention of a median cervical cyst. If an infection causes a median cervical cyst to break through in the external direction, this results in the formation of a median cervical fistula. The maldevelopment occurs primarily in the hyoid region. It is believed that the hyoid bone has an obstructive effect on the descent. As a result, the connecting duct runs either in front of or behind the hyoid bone. Likewise, a course through the hyoid bone is also possible. Lateral cervical fistulas or cervical cysts are the remnants of the gill furrows or gill arches. For this reason, they are also called branchiogenic neck fistulas. The development of the gill arches occurs between the 4th and 8th week of the embryo‘s development in the pharyngeal region. In most cases, a remnant of the second gill arch remains. During cervical development, growth of the second gill arch takes place over the third as well as the fourth arch. This process results in the formation of the cervical sinus, a cavity that usually recedes completely as it progresses. However, if this is not the case, parts or a complete duct remain. This duct may extend from the tonsillar region through soft tissues of the neck along the artery of the neck to the outer skin. Most often, it ends in the lower portion of the sternocleidomastoid muscle.
Symptoms, complaints, and signs
A cervical fistula or cervical cyst is found in most affected individuals at the hyoid bone, which forms an arch-shaped bone in the anterior portion of the neck. For the most part, a lateral cervical fistula first becomes noticeable in adults in the form of a neck thickening. As a cyst it is often present alone, whereas as a fistula it has extensions. These extend in different directions. They may include the tonsils (tonsils) or the region of the clavicle. Aside from swelling, there is usually no discomfort experienced with a cervical fistula or cervical cyst. In some patients, however, inflammation is possible, which in the worst case may even develop into a purulent abscess. Very rarely, a malignant tumor even develops at the base of the fistula.
Diagnosis and course
If the patient with his cervical fistula visits a doctor, he first deals with the patient’s medical history (anamnesis). He also performs a physical examination. A median cervical fistula can usually be palpated as a prallel elastic swelling in the middle of the neck. There is also up and down movement during the swallowing process. Seventy-five percent of all median neck fistulas or neck cysts can be detected before the age of 6. During a sonography (ultrasound examination), it is possible to identify a cavity containing fluid. Median cervical fistula may also leak pus from its opening. A lateral cervical fistula can be diagnosed by a small opening located at the anterior border of the sternocleidomastoid muscle on the lateral aspect of the neck. Purulent or milky secretion emerges. In unclear cases, further investigations such as computed tomography (CT) or magnetic resonance imaging (MRI) are performed. Because a lateral neck cyst or neck fistula can be confused with a benign or malignant tumor, respectively, a precise differential diagnosis is important.In most cases, the cervical fistula can be completely eliminated by surgical intervention. However, the recurrence of a fistula or cyst cannot be ruled out. This is especially true if a single section of fistula was not operated out.
Complications
In most cases, cervical fistula does not cause symptoms until adulthood. However, it is usually already congenital and is not acquired during life. Cervical fistula primarily causes thickening of the neck. The cysts can extend in different directions and thus lead to severe swelling. Besides the swelling, however, there are usually no further complications or complaints. In these cases, no direct treatment of the neck fistula is necessary, if it does not bother the patient. However, it is not uncommon for an abscess to develop, which can also be purulent. Infections and inflammations can develop from this abscess, which is why treatment is necessary in this case. Rarely, the formation of a tumor occurs. Treatment of cervical fistula is surgical and does not lead to further complications or discomfort. As a rule, the complete fistula is removed, so that the affected person does not suffer from any limitations even after the operation. Life expectancy is not limited by the cervical fistula. This is true even if the cervical fistula is not treated.
When should you go to the doctor?
As a rule, a neck fistula should be examined and treated when it causes discomfort. A cervical fistula without symptoms does not need to be treated, as it does not negatively affect the health of the affected person. However, since a neck fistula can also significantly reduce the patient’s aesthetic appearance, it can be removed through a surgical procedure. A dermatologist should be consulted for this purpose. Regular examinations are also recommended for this condition in order to detect and remove any degeneration and thus tumor at an early stage. The doctor should also generally be consulted if there is swelling on the neck that cannot be explained by external factors. Special complications do not occur during treatment and the neck fistula can be easily removed. After the operation, the doctor should be consulted if there is itching or postoperative bleeding at the wound. Severe pain is also rather uncommon and should be checked as well.
Treatment and therapy
As a rule, a cervical fistula or a cervical cyst is treated surgically. Although conservative therapy is possible, it is not considered promising. In addition, the deformities do not disappear on their own, so they cannot be corrected by conservative treatment. At the beginning of the operation, the patient receives either a local anesthetic or a general anesthetic. If it is a median cervical fistula, the surgeon makes a skin incision above the hyoid bone. He then removes the cyst along with a section of the hyoid bone. If a cervical fistula is present in the external direction, its excision is performed in a spindle shape. Since complete removal of the fistula is required, surgery often needs to be performed down to the initial section of the tongue. If a lateral neck cyst is present, the surgeon incises the skin at the tension lines. He pushes aside the head-nicker muscle located there in order to be able to remove the cyst as well as any fistulas. For this purpose, it is not uncommon for several skin incisions to be necessary.
Outlook and prognosis
If left untreated, cervical fistula leads to discomfort and inconvenience as the patient ages. In severe cases, there are sequelae and further illnesses. In addition to a tightness in the neck and swelling, growth of the cervical fistula may occur. Over time, there is a risk that the fistula will mutate and develop into a tumor. In the case of a malignant tumor, there is potentially a danger to the life of the affected person. If treatment is sought, the prognosis is favorable. The cervical fistula is removed in a surgical procedure. Since the area of the neck is easily accessible to the surgeon, complications are rare. Normally, the patient is discharged from the surgical procedure as symptom-free a short time after the procedure. Cervical fistula can be diagnosed immediately after birth. Nevertheless, surgery is rarely initiated within the first days of life.The timing of the procedure is determined by the necessity as well as the size of the fistula. In the case of a small cervical fistula, local anesthesia is sufficient, while a large cervical fistula is removed only under general anesthesia. In both cases, the patient should be in a stable state of health so that the healing process can take place as quickly as possible. Recurrence of the cervical fistula is not to be expected in the further course.
Prevention
Cervical fistulas are congenital impairments. For this reason, there are no preventive measures.
Aftercare
Follow-up care cannot aim to prevent recurrence of cervical fistula. Either it is present at birth or it is not. Surgery usually takes place to remove the malformation. This usually results in a final recovery. The patient can lead a carefree life and does not have to participate in any aftercare. In rare cases, however, surgery is not successful or not completely successful. Then there may be an increased susceptibility to infections and inflammations. Affected persons must consult a doctor in the event of any acute complaints. Also, sometimes a tumor forms, which can prove life-threatening. Some doctors advise not to perform surgery under general or local anesthesia if symptoms are not present. Affected persons can usually continue to live symptom-free for decades. Support in everyday life, which targets aftercare, is not necessary. Only in old age do symptoms occur more often, which a doctor then treats acutely. Thus, aftercare does not play a significant role in a diagnosed cervical fistula. Patients decide either to live with the foreign body without symptoms or to have it surgically removed. Only in cases of acute symptoms do physicians advise a presentation.
What you can do yourself
Medical treatment of a cervical fistula can be aided by a number of measures. First, bed rest and sparing apply to those affected. The body is particularly weakened after the surgical procedure, so excessive exertion should be avoided at first. In addition, dietary steps must be taken, which depend on the particular operation and can vary considerably. The operating physician will suggest a suitable diet to the patient for the period before and after the operation and give further tips for a speedy recovery. Above all, the patient must observe the wound and take good care of it. Any abnormalities such as sudden itching, post-operative bleeding or pain should be clarified immediately. In the case of multiple cervical fistulas, support may be needed for follow-up care. It is advisable to involve a trusted person or specialist nursing staff at an early stage in order to avoid complications during the healing phase. Some homeopathic remedies can be used for support. These include the preparation Apis D200 or the remedy Apis mellifica, which helps with swelling and redness. A suitable Schüßler salt is the preparation number 4, Kalium Chloratum. The use of these preparations should always be done in consultation with the competent medical practitioner.
