Branchial Cysts in Quito, Ecuador.

Images in emergency medicine

Branchial cleft or cervical lymphoepithelial cysts: Etiology and management

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

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

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

Branchial abnormalities occur when there is disturbance in the maturation of the branchial apparatus during fetal development. Branchial anomalies are congenital lesions usually present in childhood, even if they can be diagnosed later for enlargement or infection. A correct diagnosis will lead to proper management: complete surgical excision is the treatment of choice. The purpose of this article is to present clinical features, diagnostic methods and surgical treatment of branchial anomalies in childhood, based on a series of 50 patients. We conducted a retrospective analysis of a total of 50 pediatric patients operated from June 2005 to June 2014 for the presence of branchial cleft anomalies. 27 cases (54 %) presented a second branchial cleft fistula and 11 cases (22 %) a second branchial cleft cyst and one case (2 %) presented both cyst and sinus of the second branchial cleft; four cases (8 %) presented first branchial cleft cyst whereas four cases (8 %) a first branchial cleft sinus and two cases (4 %) a first branchial cleft fistula; one case (2 %) presented a piriform sinus fistula (third branchial cleft). None of our patients presented anomalies of the fourth branchial cleft. All patients underwent surgical treatment and lesions have been removed by excision or fistulectomy. No post-surgical complication occurred. The rate of recurrence was 4 %. Pre-operative diagnosis supplies important information to the surgeon for a proper therapy: a complete excision of the lesion without inflammatory signs is essential to avoid re-intervention and to achieve a good outcome.

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.

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.

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.

At the fourth week of embryonic life, the development of four branchial clefts result in five branchial arches, which contribute to the formation of various structures in the head and neck. We report a case of second branchial cleft cyst in a 50 years old lady for last 30 years. The cyst did not develop any complication in spite of long duration. The mass had been evaluated in past and she underwent ultrasonography (USG) and fine needle aspiration cytology (FNAC). Again, we evaluated the patient with USG, contrast enhanced computer tomography (CECT) and FNAC. The final diagnosis on both the occasions was lipoma neck. The mass was found to be second branchial cyst on exploration under local anaesthesia and same was confirmed by histopathology. We wish to highlight the limitation of radiology and cytology the diagnosis of branchial cleft cysts. The magnetic resonance imaging (MRI) may have clinched the exact diagnosis, which was not done in this case. The operating surgeons should always keep in mind these limitation and be prepared for surprises in dealing with the neck masses .

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.

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.

A complete second branchial fistula in a four years old child

Branchial cleft cysts are congenital anomalies that form during fetal development and originate from the second branchial cleft. They typically manifest as painless masses on the side of the neck and can become symptomatic when infected. These cysts can create a cavity that may foster infection and, in rare instances, facilitate the spread of primary tumors. It is unusual to find ectopic thyroid tissue within a brachial cyst and it is even rarer to see papillary thyroid carcinoma developing from this tissue. Whenever physicians find a case of lateral neck cyst containing thyroid neoplasm without a known primary in the thyroid, there is always a confusion about whether it is a case of metastatic disease with an undetected primary tumor, or is a carcinoma originating from ectopic thyroid tissue. This is a case report of a papillary thyroid cancer that was unintentionally discovered inside a branchial cyst. So far, only five cases akin to this have been documented. There was no sign of an underlying primary thyroid tumor after the patient had a complete thyroidectomy and selected neck dissection, according to a comprehensive evaluation. This article touches on the development of thyroid tissue within branchial cysts and discusses the etiology of lateral neck tumors. The outcome for such patients appears to be favorable after cyst excision and total thyroidectomy. This article also emphasizes the importance of doing routine histopathological examinations on surgically removed samples that look benign.