Overview
Definition:
A branchial cleft cyst is a congenital anomaly of the neck that arises from the persistence of a remnant of the second or third branchial arch
It typically presents as a smooth, non-tender mass, most commonly located anterior to the sternocleidomastoid muscle in the upper third of the neck.
Epidemiology:
Branchial cleft cysts are the second most common congenital neck mass after thyroglossal duct cysts
They account for approximately 20% of all congenital neck masses
They are typically diagnosed in early childhood, but can present in adulthood
The second branchial cleft is the most common site, accounting for over 90% of cases
There is no significant sex predilection.
Clinical Significance:
While often benign, branchial cleft cysts can lead to recurrent infections, abscess formation, and aesthetic concerns, necessitating surgical intervention
Accurate diagnosis and complete excision are crucial to prevent recurrence and complications, making this a core topic for surgical trainees preparing for postgraduate examinations like DNB and NEET SS.
Clinical Presentation
Symptoms:
Painless, slow-growing neck mass
Recurrent infections with painful swelling and erythema
Discharge from a sinus tract opening on the lateral neck
Dysphagia or hoarseness if the cyst is large or located posteriorly.
Signs:
A smooth, firm, non-tender mass typically located along the anterior border of the sternocleidomastoid muscle
A sinus tract opening may be visible, often with a history of mucoid or purulent discharge
Palpation may elicit tenderness if infected
No systemic symptoms unless infected.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a characteristic location and appearance of the neck mass, especially with a history of recurrent infections or a visible sinus tract
Imaging is often used to confirm and delineate the extent of the cyst and differentiate it from other neck masses.
Diagnostic Approach
History Taking:
Onset and duration of the neck mass
History of recurrent infections, fever, and pain
Any discharge from the neck
Presence of symptoms such as dysphagia, odynophagia, or hoarseness
Family history of similar anomalies
Previous treatments or surgeries.
Physical Examination:
Palpation of the neck for masses, noting size, consistency, mobility, and tenderness
Location of the mass relative to the sternocleidomastoid muscle, hyoid bone, and thyroid cartilage
Examination of the oropharynx for potential internal openings
Inspection of the skin for sinus tract openings or previous surgical scars.
Investigations:
Ultrasound of the neck: initial imaging modality to characterize the mass as cystic or solid and assess its relationship to surrounding structures
CT scan with contrast: provides detailed anatomical information, helps delineate the cyst extent, involvement of adjacent vessels and nerves, and aids in surgical planning, especially for complex or recurrent cases
MRI: useful for visualizing soft tissues and neurovascular structures, particularly if malignancy is suspected or for planning complex dissections
MRI can better delineate the relationship to the carotid sheath and pharynx
Culture and sensitivity of any discharged fluid if infected.
Differential Diagnosis:
Thyroglossal duct cyst: midline neck mass, typically moves with tongue protrusion
Lymphadenopathy: discrete, often mobile nodes, usually with a history of infection or systemic illness
Teratoma or other germ cell tumors: often larger, may have calcifications, and can occur in unusual locations
Abscess: tender, erythematous mass with systemic signs of infection
Cystic hygroma/lymphangioma: more diffuse, fluctuant masses, often present at birth
Schwannoma or neurofibroma: firm, palpable mass along nerve pathways, often with neurological symptoms.
Management
Initial Management:
For infected cysts, initial management involves antibiotics (e.g., amoxicillin-clavulanate, clindamycin) and aspiration if fluctuant, followed by elective surgical excision once the infection has resolved
Non-infected cysts are typically managed with elective surgical excision.
Medical Management:
Antibiotics are crucial for managing infected branchial cleft cysts
Common regimens include broad-spectrum antibiotics such as amoxicillin-clavulanate (875mg/125mg twice daily for 7-10 days in adults) or clindamycin (300mg three times daily for 7-10 days in adults) for penicillin-allergic patients
Pain management with analgesics like paracetamol or NSAIDs may also be necessary.
Surgical Management:
Surgical excision (branchial cleft cystectomy) is the definitive treatment
The goal is complete removal of the cyst and any associated sinus tracts to prevent recurrence
The approach is typically a transcervical incision along the anterior border of the sternocleidomastoid muscle
Careful dissection is required to identify and preserve the underlying hypoglossal nerve, vagus nerve, and carotid artery
For second branchial cleft cysts, the tract often extends superiorly towards the tonsillar fossa, necessitating dissection close to the superior constrictor muscle and palatine tonsil
Excision of the involved portion of the tonsil may be required for complete removal of the tract
For recurrent cysts or those with extensive tracts, a more extensive dissection or even pharyngotomy may be needed
Recurrence rates are significantly lower with complete excision.
Supportive Care:
Postoperative care includes pain management, wound care to prevent infection, and monitoring for complications like hematoma, seroma, or injury to adjacent structures
Patients are typically kept on a liquid or soft diet for the first few days if oropharyngeal dissection was extensive
Prophylactic antibiotics may be considered in certain cases.
Complications
Early Complications:
Hemorrhage (intraoperative or postoperative hematoma)
Infection of the surgical wound
Seroma formation
Injury to the hypoglossal nerve (tongue deviation)
Injury to the vagus nerve (hoarseness)
Injury to the phrenic nerve (diaphragmatic paralysis)
Injury to the recurrent laryngeal nerve (vocal cord paralysis)
Chyle leak.
Late Complications:
Recurrence of the cyst due to incomplete excision
Persistent sinus tract
Scarring at the incision site
Damage to cranial nerves leading to long-term functional deficits.
Prevention Strategies:
Meticulous surgical technique with complete cyst and tract excision
Careful identification and preservation of vital neurovascular structures
Thorough hemostasis
Appropriate antibiotic use perioperatively
Close follow-up to detect early signs of recurrence.
Prognosis
Factors Affecting Prognosis:
Completeness of surgical excision is the most critical factor
Younger age at initial presentation may be associated with a higher risk of recurrence if not completely excised
Presence of multiple branchial cleft remnants
Surgical expertise.
Outcomes:
With complete excision, the prognosis is excellent, with low recurrence rates and minimal long-term sequelae
The vast majority of patients achieve a cure
Recurrent cysts may require more complex surgery and have a higher chance of recurrence.
Follow Up:
Postoperative follow-up typically involves wound checks for early complications
Long-term follow-up is generally not required for uncomplicated cases
However, if there is any suspicion of recurrence or persistent symptoms, further evaluation with imaging or examination may be necessary.
Key Points
Exam Focus:
Second branchial cleft cysts are the most common, presenting as lateral neck masses anterior to the sternocleidomastoid muscle
Complete surgical excision is the definitive treatment
Recurrence is high with incomplete removal
Differentiate from thyroglossal duct cysts (midline) and lymphadenopathy.
Clinical Pearls:
Always palpate for a sinus tract opening
Be aware of the typical trajectory of second branchial cleft cysts towards the tonsillar fossa
Careful dissection is paramount to avoid cranial nerve injury, especially the hypoglossal and vagus nerves
Consider ultrasound as the first-line imaging modality for suspected congenital neck masses.
Common Mistakes:
Incomplete excision leading to recurrence
Mistaking a branchial cleft cyst for a simple lymph node or other neck mass
Aggressive dissection causing iatrogenic injury to nerves or vessels
Delaying surgery in infected cysts until infection has resolved, leading to further complications.