Abstract
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.
Highlights
First branchial cleft anomalies are rare, accounting for only 10% of all branchial cleft anomalies
Final pathology of the tissue excised from both the ear and parapharyngeal regions was consistent with the diagnosis of a first branchial cleft cyst, revealing cystic spaces filled with keratin debris and lined by stratified squamous epithelium containing pilosebaceous units (Fig. 3a and b)
Histopathological analysis of our case is in favor of a first branchial cleft cyst given the absence of both respiratory epithelium and associated lymphoid tissue, two common findings in second branchial cleft cysts [7]
Summary
We hereby describe an unusual presentation of a first branchial cleft cyst with a pharyngeal extension, possibly a hybrid first and second branchial cyst. Otolaryngologists should keep this possibility in mind when evaluating a child with both otologic and neck symptoms. Thorough pre-operative radiologic workup should aim at establishing the presence of a connecting fistulous tract. Operative management is greatly aided by combining traditional and robotic approaches
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