Branchial cleft cyst with subcarinal and posteroinferior mediastinal localization: what would be your most likely interpretation based on preoperative images?

Images in emergency medicine

The term "branchial cleft cyst" refers to the lesions that can be considered synonymous with cervical lymphoepithelial cysts. Although relatively rare, they constitute the second major cause of head and neck pathologies in childhood. This study aimed to report the clinical presentations, diagnosis, and management of pediatric patients with the pathological diagnosis of branchial cleft cyst. This study was a retrospective analysis of the records of 33 patients with the diagnosis of branchial cyst, in two different university hospitals, in two different populations. Thirty-three cases of branchial cleft cysts were seen in 33 patients: 17 females and 16 males. The majority (16 patients) were 2nd branchial cleft cysts. Accurate diagnosis of branchial cleft malformation was made via imaging in 20 of the 21 (95%) patients that underwent preoperative surgical ultrasonographic imaging. Branchial cleft cysts are frequently incorrectly diagnosed and ignored in the differential diagnosis. Thus, the diagnosis is often delayed, resulting in the mismanagement of affected patients. A branchial cyst should be suspected in any patient with a swelling in the lateral aspect of the neck, regardless of whether the swelling is solid or cystic, painful or painless. The use of ultrasonography can dramatically help clinicians with distinguishing branchial cleft cysts from other similar lesions of the head and neck.

Branchial cleft or cervical lymphoepithelial cysts: Etiology and management

Two patients (a 58-year-old man and a 58-year-old woman) had branchial cysts in the parotid gland, and the other patients had one in the submandibular gland. Branchial cysts usually occur in the lateral cervical area and are rare in salivary glands. Branchial cysts in salivary glands are classified as first branchial cleft cyst and second branchial cleft cyst depending on the site of origin.First branchial cleft cysts are rarer than second branchial cleft cysts and usually appear in the preauricular area. The cysts are lined with stratified squamous epithelium, and scant lymphoid tissue is seen in the subepithelial area. Second branchial cleft cysts usually occur in the lower portion or superficial lobe of a parotid gland. They are lined with stratified squamous epithelium plus columnar or cuboidal epithelium. Beneath which is abundant lymphoid tissue with clear lymphoid follicles. Clinical and pathological examinations showed that the two parotid gland cysts were probably second branchial cleft cysts and the one in the submandibular gland was probably a first branchial cleft cyst.

Multidetector computerized tomographic fistulography in the evaluation of congenital branchial cleft fistulae and sinuses

The ultrasonic diagnosis of cervical and facial cystic masses, as well as cases of missed diagnosis and misdiagnosis, was examined, to improve the diagnosis of branchial cleft anomalies. A retrospective analysis was conducted on 17 patients with branchial cleft cyst anomalies, including 11 males and 6 females, aged 12-53years, with an average age of 33 ± 2years, were unilateral single. All patients who underwent an ultrasound examination and image storage for retrospective analysis, and both longitudinal and transverse sections were scanned to observe the shape, size, boundary, peripheral relationship, and blood flow signal of the masses. All cases were examined with an enhanced CT scan, and pathological reports were generated. Among the 17 cases of branchial cleft anomalies, 15 cases were branchial cleft cysts, while one case involved fistula formation and one case involved sinus tract formation. Based on the type of branchial cleft, the first, second, and third cysts were classified in 4, 12, and 1 case, respectively. The sensitivity rate and specificity of ultrasonic diagnosis were 14/17 (82.4%) and 4/6 (66.7%), respectively. Ultrasonic characteristic analysis for the masses can be found in simple cystic masses or hypoechoic masses, most of them are of a regular shape and have a distinct boundary, and almost no blood flow signal. All patients who were misdiagnosed exhibited blood flow signals, including 1 patient with an abundant blood flow signal, 1 patient suspected of having ectopic thyroid with an abnormal function due to the rat-tail sign, 2 patients misdiagnosed as local inflammatory focus, and 1 patient misdiagnosed with tuberculous lymphadenitis. Ultrasound has a detection rate of up to 100% for cervical and facial masses, providing a fundamental determination of lesion characteristics and specific guidance for preoperative diagnosis. If the blood flow signals can be identified and carefully considered their peripheral relationship, the diagnostic rate can be improved.

Conclusions: Metastatic disease should always be considered as a potential differential diagnosis in the adult patient with a cystic neck lesion. Objectives: The most common cause of a cystic neck lesion in young adults is a branchial cleft cyst (BCC). In older patients metastatic lymph nodes may be easily misdiagnosed as BCC. This study aimed to investigate the incidence of unsuspected carcinoma in routinely excised cervical cysts at a tertiary care teaching hospital and to determine the characteristics of benign BCC and cystic malignancy in preoperative imaging. Patients and methods: A total of 196 consecutive adult patients operated on with the initial diagnosis of benign lateral cervical cyst were identified and the hospital charts and imaging studies were reviewed. The mean age of the patients was 40 years (range 17–79 years). Results: Metastatic squamous cell carcinoma was demonstrated histologically postoperatively in six (3.1%) patients and metastatic papillary thyroid carcinoma in one (0.5%) patient. Therefore, the incidence of unsuspected carcinoma in the cystic neck lesions initially diagnosed as BCC was 3.6%. The preoperative imaging appearances of these lesions had been considered identical to that of BCC.

Intrathyroidal branchial cleft cyst is a rare entity in otolaryngology practice with few cases reported in the literature. Clinically, it mimics a thyroid swelling and the diagnosis is confirmed only by histopathology. The cyst walls are lined by predominantly non-keratinizing stratified squamous epithelium with characteristic subepithelial lymphoid tissue. This is a case report of right intrathyroidal branchial cleft cyst in a 50-year-old and a left intrathyroidal branchial cleft cyst in a twelve- year-old boy. Both patients underwent imaging followed by surgical management. A fourth branchial cleft cyst is very rare and may have varied presentation. Both patients with intrathyroidal branchial cleft cysts had complete surgical excision and are normal during regular follow ups. The presentation of a fourth branchial cleft cyst may occur as an intrathyroidal swelling. The recommended treatment of an intrathyroidal branchial cleft cyst is complete surgical excision of the branchial cyst with thyroidectomy. Misdiagnosis of a fourth branchial cyst can result in incomplete removal leading to recurrence. Awareness about the clinical manifestations of a fourth branchial anomaly is crucial for appropriate management.

Papillary thyroid carcinoma (PTC) in a branchial cleft cyst (BCC) is exceedingly rare. This case report describes a 53-year-old male with a BCC containing PTC. Despite normal preoperative thyroid imaging, total thyroidectomy revealed multifocal bilateral micropapillary thyroid carcinoma with a contralateral metastatic lymph node, suggesting an aggressive disease course. This finding supports the likelihood that thyroid gland carcinoma metastasized to the BCC. However, the possibility of a primary tumor arising from ectopic thyroid tissue within the cyst cannot be excluded. To our knowledge, this is the 11th reported case of papillary thyroid cancer noted in a BCC. The patient underwent successful treatment, including radioiodine ablation, highlighting the importance of thorough diagnostic evaluation and management in such rare presentations. While most BCCs are benign, PTC can very rarely present within BCC. Metastatic PTC with a necrotic lymph node is often misdiagnosed as BCC, both radiographically and histologically. Since PTC arising as a primary tumor from ectopic thyroid tissue within a BCC is extremely rare, total thyroidectomy should be considered even in patients with radiographically normal thyroid to rule out micropapillary primary thyroid tumors. A thyroglobulin assay from the needle washout of a fine-needle aspiration of a BCC may help preoperatively identify differentiated thyroid cancers. Micropapillary thyroid cancers (<1 cm) are usually indolent, but some may show nodal metastases and clinical progression.

Type II first branchial cyst and sinus excision with preservation of facial nerve and parotid gland

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

Branchial cleft cyst is a well-known head and neck anomaly. Patients commonly presented with cosmetic problems. Complications including pressure symptoms, pain and superimposed infection have been reported. Rarely, it could present with carotid sinus syndrome. Case report We reported a case who presented with vasovagal syncope and cardiogenic shock was found to have huge branchial cleft cyst. Carotid sinus syndrome secondary to compression by the branchial cyst was suspected. It was managed with inotropic support and needle decompression. She later readmitted for superimposed infection which was treated by antibiotics. Surgical excision was performed to render her complete cure. This was the second reported case of a benign branchial cleft cyst causing cardiac compromise in the literature. Conclusion Benign branchial cleft cyst may present with lifethreatening carotid sinus syndrome. Timely needle decompression should be performed for temporary relieve and definitive surgery is required for cure. How to cite this article Yam SDF, Fung TLD, Tang LCD. Life-threatening Cardiac Failure: A Rare Complication of Branchial Cleft Cyst. Int J Head Neck Surg 2014;5(3):158-160.

Branchial cysts are congenital anomalies. Very few cases have been reported about branchial cysts with mediastinal extension. We report here a case of branchial cysts with mediastinal extension. INTRODUCTION: Branchial cysts (also known as lateral cervical cysts), predominantly present in the lateral aspect of the neck. Branchial cleft cysts are congenital anomalies. Typically, a fluctuant swelling is felt deep to the sternocleidomastoid at the junction of its upper third and lower two thirds. They often present in the second and third decades of life. No racial or sexual predilection has been identified. Males and females are equally affected and there is occasionally a hereditary tendency. Diagnosis is usually made clinically. Branchial cleft cysts are benign; however, super infection, mass effect, and surgical complications account for morbidity. Patients relate its discovery to an attack of pharyngitis, ear infection, or dental infection, and many report temporary enlargement with or without tenderness during periods of upper respiratory tract infection. Inflamed cysts may progress to abscess formation with the possibility that rupture or incision and drainage will lead to either permanent sinus formation or to recurrent cyst formation and infection. Recurrence rates are reported. CASE REPORT: A previously well 12 year old girl presented to outpatient department with a two month history of left sided neck swelling & associated symptoms of mild discomfort in the region of neck swelling & mild degree of odynophagia. There was no history of and respiratory compromise. Past medical history was unremarkable & she was on no regular medications. On examination, a large about 8x3 cm size left neck swelling noted limited posteriorly by the ipsilateral sternocleidomastoid muscle. The mass was soft in consistency, fluctuant & non-tender. No visualized engorged veins noted over the swelling. There was no evidence of fistula. No other mass or abdominal examinations were normal with no evidence of any organomegaly. The full blood counts were within normal limits. Chest X-ray was also unremarkable. A hematological referral was made & ultrasound of the neck was advised. USG –neck revealed a cystic mass in the left side of the neck extending inferiorly up to the ipsilateral supraclavicular region. The inferior most aspect of the lesion could not be delineated. For further evaluation a MRI scan of the neck was done on a Siemens MR scanner using IV contrast. Routine T1 wt. & T2 wt. as well as post contrast T1 wt. images were taken in axial, sagittal & coronal planes. Post contrast T1 wt. coronal image demonstrates a left sided neck mass with a hypointense centre & isointense peripheral margins & no evidence of any enhancements (Fig-1). T2 with axial image shows a hyperintense looking mass in the left side of neck limited posteriorly by the ipsilateral sternocleidomastoid muscle & it is also extending into the left Para pharyngeal space displacing the carotid vessels (Fig-2). T2 wt. coronal image demonstrates

Introduction Branchial cleft anomalies are the second most common congenital anomaly in children. However, some lesions may not develop clinically and are not diagnosed until adulthood. The recent literature of branchial cysts (BCs) in the adult population is really scanty. For this reason, we analyzed the clinical and surgical management of the adult population treated for a BC at a tertiary care general hospital. Methods A retrospective review of the clinical records of all the patients with histological diagnosis of BC who were surgically treated at the Social Security Hospital in Quito, Ecuador, was performed. Fifty-one patients (27 women) with congenital anomalies of the 2 nd (43 patients with cysts) and 3 rd (6 patients with cysts and 2 with fistula) branchial arches were diagnosed and treated. Diagnosis was made on clinical grounds and by computed tomography scan. Results The 43 patients with a 2 nd branchial cleft cyst underwent complete surgical excision through a wide mid-neck transverse cervicotomy. The 6 cases of 3 rd branchial cleft cyst underwent surgical resection through a lower-neck transverse incision, and the 2 patients with clinical fistula in the lower aspect of the neck were operated on via an elliptical incision around this external fistula opening. Postoperative evolution was uneventful in all patients. Conclusions Branchial cysts can occasionally be diagnosed in adult patients in the setting of a general hospital population. A correct clinical and imaging assessment was diagnostic in most patients. Complete surgical resection was curative in all our patients, and postoperative complications were exceptional.

Lateral cervical cysts are usually considered as of branchial cleft origin, despite many studies showing that branchial cysts do not arise from the remnants of the branchial apparatus. In the same way, some authors still consider that a true clinicopathological entity such as 'branchial cleft cyst carcinoma' could exist, at least in theory. Despite insufficient evidence in support of the branchial theory, a number of publications continue to emphasise this concept. A literature review of articles in Medline and PubMed databases was carried out to retrieve papers relevant to the topic. The evidence from lateral cervical cyst studies and knowledge about cystic metastasis of Waldeyer's ring could be applicable for both diagnoses. Terms such as 'branchial cleft cyst' and 'branchial cleft cyst carcinoma' are confusing and misleading, and it is questionable as to whether their usage is still tenable.