A Second Branchial Cleft Cyst Presenting as a Dumbbell -Shaped Anterior Neck Mass

Images in emergency medicine

<p>Branchial cleft anomalies comprise approximately 30% of congenital neck mass and present as cyst, sinus or fistula. They occur due to disturbance in the maturation of the branchial apparatus during fetal development. They are congenital lesions usually present in childhood, but they are usually diagnosed in later childhood or early adulthood because of enlargement or infection. Branchial cleft fistulae are usually diagnosed earlier than cysts. Correct diagnosis leads to proper management. Complete surgical excision is the treatment of choice. Second branchial cleft and pouch anomalies are commonest amongst all branchial cleft lesions, but complete second branchial cleft anomalies with external and internal opening is rare. Branchial anomalies with family history are also very rare. Here we present a case report of complete branchial fistula with family history which was managed by complete excision of fistula through transcervical and transoral approaches. 3 members of one family in 2 generations presented with branchial apparatus anomalies (father and his two children, elder son and younger daughter). All of them were having branchial fistula on right side of neck since birth.</p>

Nonsyndromic bilateral second branchial cleft fistulae: A case report

Branchial cleft anomalies (BCAs) are developmental malformations of the head and neck region. Their histogenesis has been the subject of controversy and is not fully understood. This study aimed to test all present developmental theories ("branchial apparatus," "precervical sinus," "thymopharyngeal," and "inclusion" theories) on a sample of 48 BCAs from a single institution. We performed a retrospective analysis of clinical-epidemiological and anatomical-pathological characteristics of BCAs treated over a 12-year period in our hospital. Overall, 46 patients (24 [52.17%] women and 22 men [47.83%]) underwent surgical excision of 48 BCAs. The mean patient age at presentation was 31.65 ± 19.40years. Branchial cleft cysts were found in 42 (87.50%) cases, and branchial cleft sinuses were found in six (12.50%) cases. Eight (16.67%) BCAs were distributed in the preauricular region, 34 (70.83%) at the anterior border of the sternocleidomastoid muscle (SCM), three (6.25%) at the posterior border of the SCM, two (4.17%) in the suprasternal notch, and one (2.08%) in the retrosternal space. Histopathologically, 39 (81.25%) BCAs had a lymphoepithelial structure and nine (18.75%) BCAs had solitary epithelial cells. Inflammation and infection were observed in 24 (50%) and 12 (25%) cases, respectively. None of the hypothesized developmental theories fully explain the embryonic origin of BCA in our study sample. A possible explanation of BCA histogenesis is through the hybrid "branchial inclusion" theory.

A 13-month-old female was brought to the emergency department by her mother for 2 days of left neck swelling (Figure 1). Per her mother, the patient had developed progressive swelling and erythema after scratching the area over the last week. Otherwise, she was asymptomatic with normal vital signs. Before the patient's swelling, there had been a “dimple” at the area since birth. A point-of-care ultrasound was performed, demonstrating a 2.1 × 2.3 × 2.1 cm cystic and heterogeneous structure (Figure 2). Infected Branchial Cleft Cyst. Branchial cleft anomalies are remnants of branchial cleft mucosa during embryogenesis.1, 2 Incomplete involution of the mucosa create vestigial cysts, sinuses, and/or fistulas. There is a predilection for branchial cleft anomalies on the left side, more common in females, and second branchial cleft anomalies are the most common.3 Branchial cleft cysts present as a painless soft tissue mass around the anterolateral neck, along the anterior sternocleidomastoid muscle. If infected, they can become swollen and tender. Rarely, the cyst can lead to complications of airway compromise and glossopharyngeal and hypoglossal nerve compression due to mass effect.4 Clinical and radiological diagnostics can raise suspicion for branchial cleft cysts. Definitive diagnosis is made with cyst excision and histological examination, demonstrating a cystic cavity lined by epithelium and underlying connective tissue showing germinal centers.4 Other diagnoses to consider for pediatric superficial neck masses are lymphadenopathy, thyroglossal duct cyst, or dermoid cyst. Conservative treatment of needle aspiration, incision and drainage, and injection of sclerosant agents may be trialed, but recurrence is common.1-4 Definitive treatment is surgical excision.

Type 2 branchial cleft anomalies are the most common cause of lateral neck swelling. We report two cases of type 2 branchial cleft anomalies. The first case is branchial cleft cyst and the second one is branchial fistula. Both cases were managed surgically. The post operative outcomes were uneventful. Second branchial cleft anomalies are the most common branchial anomalies. Branchial cysts are more common than sinuses and branchial fistulae are extremely rare. There is no gender predilection. The location, clinical symptoms and imaging findings aid in the diagnosis of this condition. Surgical excision is the mainstay of treatment.Keywords: branchial cleft; branchial cyst; branchial fistula.

Objective: Branchial cleft anomalies present fairly commonly in children as lateral neck masses. However, the diagnosis of such anomalies may not always be straightforward. This study seeks to review the distribution of branchial cleft anomalies in an Asian pediatric population, and highlight the challenges involved in diagnosis. Method: A retrospective chart review was performed of all pediatric patients who underwent surgery for branchial cleft anomalies between 2007 to 2011 in a tertiary pediatric hospital. The clinical notes were correlated with preoperative radiological investigations, intraoperative findings, and histology. Classification of the branchial cleft anomalies was attempted from the results. Results: Twenty-six children underwent surgery for 27 branchial cleft anomalies in the 4-year period; 1 child had excision of bilateral fourth branchial cleft sinuses. There were 7 patients (25.9%) with first, 5 patients (18.5%) with second, 2 patients (7.4%) with third, and 3 patients with 4 (14.8%) fourth branchial cleft anomalies. Six patients (22.2%) had branchial anomalies that were thought to be originating from the pyriform sinus, but we were unable to tell if these were from the third or fourth branchial clefts. The remaining 3 patients (11.1%) did not have adequate information for us to classify the level of anomaly. Conclusion: The incidence of second branchial cleft anomalies appears to be lower in our Asian pediatric population, with a higher incidence of third and fourth branchial cleft anomalies. Knowledge of the embryology and related anatomy of branchial clefts is crucial in helping to identify the type of branchial cleft anomaly present.

First branchial cleft anomalies are uncommon paediatric congenital lesions that may present as persistent pre-auricular or post-auricular sinuses and can involve the parotid region and facial nerve. We present a single-centre 10-year experience describing presentation, imaging, management and outcomes. Retrospective review of a prospectively collected local dataset of paediatric patients with first branchial arch cleft cysts/tracts who underwent evaluation and surgery at a tertiary paediatric centre. Data elements included age at presentation, presenting symptoms, imaging modality, surgical treatment, postoperative complications, facial nerve dysfunction, fistula course, recurrence and follow-up. Eleven patients were included (mean age 5.55 years, median 4 years). The commonest presentation was a persistent sinus with purulent discharge (9/11). Laterality was predominantly left-sided (8/11). MRI was the most used imaging modality (8/11). Postoperative wound infection occurred in 3/11 patients (27%); marginal mandibular branch weakness was recorded in 2/11 (both documented as transient/resolved). One patient had documented recurrence. The fistula/tract most commonly tracked from level II to the ear canal (9/11). In this paediatric series, first branchial arch cleft anomalies most commonly presented as persistent left-sided sinuses with purulent discharge. MRI was commonly used for preoperative assessment. Surgical excision was associated with wound infection in a minority and transient marginal mandibular weakness in several cases. Larger multi-centre series with systematic prospective follow-up are needed.

The objective of this study was to review the clinical characteristics and surgical treatment outcomes of second branchial cleft anomalies, and to evaluate the usefulness and accuracy of preoperative fine-needle aspiration cytology (FNAC) in the diagnosis of branchial cleft cysts. A retrospective chart review was performed at Chonnam National University Hwasun Hospital from January 2010 to December 2016. Among 25 patients with second branchial cleft anomalies, in 23 patients (92.0%), these anomalies presented as cysts, and in the remaining 2 patients (8.0%), these anomalies presented as fistulas. Fine-needle aspiration cytology had a diagnostic sensitivity of 100%, a positive-predictive value of 100%, and accuracy of 100% for diagnosing second branchial cleft cyst. All patients of second branchial cleft anomalies were treated surgically under general anesthesia. No recurrence of second branchial cleft anomalies was observed. Branchial cleft cysts were the most common type of second branchial cleft anomalies. Preoperative FNAC is a useful and accurate method for preoperative evaluation of branchial cleft cysts. Surgical excision of second branchial cleft anomalies is the treatment of choice without any complications and with no recurrence.

Background: First branchial cleft anomaly exhibits variable clinical features, ranging from a painless swelling, discharging sinus or pit, to recurrent infection. It could be easily misdiagnosed and mismanaged, resulting in recurrence. Hence, any swellings or pits in Poncet’s triangle with a history of recurrent infection should raise the suspicion of a first branchial cleft anomaly. Objective: To present a case of chronic non-healing wound caused by an incompletely excised first branchial cleft anomaly. Methods: Case observation of a patient with a history of incomplete excision of a first branchial cyst. Results: Our patient was a case of incompletely excised first branchial cyst which subsequently presented as a chronic non- healing wound. She had undergone several workup for non-healing wound resulting in delay in receiving definitive treatment. Conclusion: Early recognition of first branchial cleft anomalies is important to prevent chronic complications and mismanagement.

First branchial cleft anomalies are rare and their various anatomical relationships to the facial nerve have been described. We encountered a 15-year-old female with a type II first branchial cleft cyst presenting as a right neck mass that we found during surgical excision to transverse two main facial nerve trunks. To our knowledge, this is the first reported case of a first branchial cleft anomaly in conjunction with a duplicated facial nerve trunk.

Third branchial cleft anomaly presenting as a retropharyngeal abscess

BackgroundFirst branchial cleft anomalies are rare, accounting for only 10% of all branchial cleft anomalies. We report an even more rare and unique case of a branchial cleft cyst with features of both first and second arch derivatives.Case presentationA 6-year-old boy presented to us with a left conductive hearing loss associated with pre-tympanic keratin debris and an ipsilateral painful cervical mass. He had a past medical history of left ear surgery for presumed cholesteatoma 2 years prior and left neck abscess drainage 6 months prior. CT and MRI revealed a lesion originating in the external auditory canal and extending cervically through a bony canal located medial to the facial nerve and terminating as a parapharyngeal cyst. The complete removal was accomplished in one surgical stage consisting of three distinct steps: robotic assisted transoral resection of the pharyngeal cyst, an endaural approach and a parotidectomy approach.ConclusionWe believe that our detailed description of this rare first branchial cleft cyst with pharyngeal extension, possibly a hybrid case between a first and second branchial cyst, can serve as a valuable tool to Otolaryngologists – Head and Neck Surgeons who come across a similar unusual presentations.

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System

Background: Branchial cleft anomalies are of five types. Among these, second branchial cleft anomalies are the most common developmental disorders. The aim of the study was to evaluate the clinical data in various subsets among the patients who had been diagnosed and treated for second branchial anomalies in the past 2 years. Materials and Methods: The present study was a retrospective study conducted from January 2018 to January 2020 in our institute. We collected the clinical data from patient’s medical records, radiological reports, surgical files, and histopathological reports. Results: A total of 22 patients presented with second branchial cleft anomalies. Among these, 18 (81.8%) were branchial cysts and 4 (18.2%) were branchial sinuses. There was no branchial fistula. The highest number of cases belonged to the second decade (72.7%). The mean age was found to be 16.8 years. The male-to-female ratio was 1.75:1. The rural-to-urban ratio was 3.4:1. There was no proclivity to any one side of the neck. All 22 patients underwent surgical excision as the treatment. There was no recurrence. Conclusion: We concluded that branchial cysts are the main type among second branchial cleft anomalies. Most patients belonged to the second decade of life. Early detection and reaching correct diagnosis are the major factors influencing treatment outcome. Preferably, surgical excision has to be performed in noninfected neck. Meticulous dissection helps in avoiding recurrence. Genetic disorders such as branchio-oto-renal syndrome have to be kept in mind in the evaluation of any branchial cleft anomalies.