Branchial cleft or cervical lymphoepithelial cysts: Etiology and management

Cervical lymphoepithelial cyst: Case report and literature review

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.

Images in emergency medicine

Lymphoepithelial cysts, which are also known as branchial cleft cysts, commonly occur in the lateral cervical region. Lymphoepithelial cysts arising in the parotid gland are rare and must be distinguished from parotid gland tumors. Magnetic resonance imaging (MRI) is useful for diagnosing parotid gland lesions, and MR images of lymphoepithelial cysts typically display a cystic mass that appears homogeneously hypointense on T1-weighted images and homogeneously hyperintense on T2-weighted images. However, some parotid gland tumors that retain fluid in their inner sections show similar MRI findings to lymphoepithelial cysts. Furthermore, lymphoepithelial cysts are sometimes modified by inflammation, and these cases are hard to diagnose. We report the case of a 59-year-old female with a lymphoepithelial cyst that arose in the parotid gland. The cyst had been affected by inflammation and displayed atypical imaging findings, i.e., heterogeneous signal intensity of the liquid component and the presence of a well-enhanced capsule-like structure surrounding the liquid component. In addition, we compare the MRI findings of this case with those of two other cervical lymphoepithelial cysts.

Lymphoepithelial cyst of the parotid gland--a case report.

Lymphoepithelial (so-called branchial) cyst within the parotid gland. Report of a case and review of the literature

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

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.

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.

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: Most of the branchial cysts (>90%) come from the second branchial arch. These are originated from an embryonic defect consisting of the lack of fusion between de second branchial arch and the basal portion of the fourth cleft, causing the interiorization of the ectodermic tissue of the laterocervical area. The cyst and the fistula may sometimes go from the medium area of the sternocleidomastoid (SCM) muscle to the tonsillar region. Rarely, they appear in the childhood and they are usually asymptomatic. Only if the cyst is infected, the patient consults about the appearance of a laterocervical tumor. Surgery is the treatment of this disease when symptomatic by removing the cyst and its fistulae, if it exists. METHODS: A 52-year-old patient goes to Emergency department to discard the presence of a left peritonsillar abscess. The patient doesn’t report odynophagia, dysphagia, trismus nor fever. The only symptom he reports is dyspnea in supine decubitus. When he is checked, a great bulging of the anterior tonsillar pillar is seen, blocking nearly all the oropharyngeal space and moving the uvula to the right. An aspiration-puncture is made without purulence drainage. When an endoscopy is made, the hypopharynx and larynx are medializated. A CT scan shows the presence of a left parapharyngeal cystic mass, with a 5.1x2.5cm diameter, surrounded by a thin wall that captures contrast. It is located medially to de SCM muscle and between the internal and external left carotids, blocking the airway. This tumor is suitable for a second cleft branchial cyst. An elective surgery is decided, performing a left cervicotomy to partially remove and marsupialize the cyst. Nowadays, the patient has a left Horner syndrome because of the handling of the carotid during the surgery. CONCLUSIONS: The second branchial arch cysts are the most frequent branchial cysts. When a peritonsillar abscess is suspected and no typical symptoms are featured, a second branchial cyst may be included in the differential diagnosis. The use of images is very important to confirm the diagnosis and acknowledge the patient’s anatomy in order to prepare a surgery.

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.

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

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

CERVICAL LYMPHOEPITHELIAL CYST: A CASE REPORT