Second Branchial Cleft Cyst

Papillary Thyroid Carcinoma Concealed Within a Branchial Cyst Without Primary Thyroid Involvement: Unveiling the Enigma

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.

Occult Metastatic Papillary Thyroid Cancer in an Adolescent

Background/Objective

Occult papillary thyroid carcinoma (PTC) is PTC with metastasis but without identification of primary thyroid cancer on preoperative ultrasonography. Published reports on occult PTC in children are limited.

Case Report

We describe a 16-year-old female with occult PTC who initially presented with a painless left sided cystic neck mass. Diffuse sclerosing variant papillary thyroid cancer was found in the resected neck mass and thyroid ultrasound did not show any nodules or features of carcinoma. After total thyroidectomy, pathological examination of the thyroid revealed papillary thyroid microcarcinoma.

Discussion

We describe a rare case of occult diffuse sclerosing variant papillary thyroid cancer presenting as a cystic neck mass mimicking a second branchial cleft cyst in an adolescent patient. When metastatic PTC is found without evidence of nodule on thyroid imaging, occult PTC of the thyroid is the likely diagnosis.

Conclusion

Total thyroidectomy ± neck dissection followed by TSH suppression and radioactive iodine therapy remains the appropriate diagnostic and therapeutic interventions.

The Role of Ipsilateral Tonsillectomy in the Extirpation of Branchial Cleft Anomalies- A Retrospective Monocentric Analysis Over 13 Years

Backround

Branchial cleft anomalies (BCA) can occur as sinuses, fistulas or cysts. They arise from the first, second, third or fourth pharyngeal cleft due to non-fusion or subinvolution. Mostly, located in Robbin's neck-level II, BCA clinically present as a painless compressible swelling, cutaneous draining sinus, or fistula.

Aims

Surgical treatment is the gold standard to prevent recurrence in BCA, though the necessity of ipsilateral tonsillectomy is discussed and was being examined within this work.

Methods

In retrospect, data was collected from patients, that were admitted with the diagnosis BCA between 2006 and 2020 in an academic tertiary care center. 160 patients met inclusion criteria, the data was further evaluated, the focus was set on the occurrence of recurrence.

Results

Recurrence of BCA was observed in 2 out of 160 surgically treated patients (1,25%), one of them with simultaneous tonsillectomy, the other without.

Conclusion

A statistically significant difference in the recurrence-rate between these two groups (with/without tonsillectomy) could not be shown. The performance of an ipsilateral simultaneous tonsillectomy in the surgical workup of BCA cannot be recommended at the basis of our data.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03543-5.

The Outcome of Treatment in Second Branchial Cleft Anomalies: A Case Series

Background Branchial-cleft anomalies are second only to thyroglossal duct anomalies among congenital malformations of the neck, and second branchial-cleft anomalies are the most common. These include branchial cysts, branchial sinuses, and branchial fistulas. Clinical symptoms include neck swelling and a discharging sinus or fistula opening. In a small number of cases, they can lead to major complications like abscesses or malignant changes. Surgical resection is the treatment of choice. Various approaches to resection and sclerotherapy have been tried. In this study, we present our treatment outcome with branchial cleft anomalies at a rural tertiary medical care hospital. Objectives To document the various presentations, clinical features, and outcomes of treatment with second branchial cleft anomalies. Methods This retrospective observational study included 16 patients operated on for second branchial-cleft anomalies. A detailed medical history was elicited, and an accurate clinical examination was done. A contrast-enhanced computed tomography (CECT) scan was done in all cases. A few cases required a fistulogram. The cysts, sinuses, or fistulas were resected en bloc by a single neck crease incision. Primary closure was done in all cases. A recurrence or pharyngocutaneous fistula required axial flap reconstruction. The complications and recurrences were documented. Result There were six children and 10 adults in our study. Seven cysts, five sinuses, and four fistulas were present, of which four were iatrogenic. In seven patients, imaging could not show the entire tract. There were four fistulas from the oropharynx to a cutaneous opening in the neck. A complete resection was done for all. Two pharyngocutaneous fistulas were treated with a pectoralis major myocutaneous (PMMC) flap. Three patients had wound dehiscence postoperatively. None of the patients had neurological or vascular injuries. Conclusion Second branchial cleft anomalies can be completely excised by a single neck crease incision. Meticulous surgery results in a low recurrence or complication rate. Following complete excision, in type IV anomalies, a purse-string suture at the pharyngeal opening ensures good closure and no recurrences.

Coexistence of thyroglossal duct cyst and second branchial cleft cyst in a young woman: A case report and literature review

Introduction

Thyroglossal cysts represent 70% of congenital neck anomalies, and second branchial cleft anomalies are the most common anomalies (90%) of the branchial apparatus. However, their coexistence, especially in adults, is very rare.

Presentation of case

A 23-year-old woman presented with a 1-year history of lateral left neck swelling and midline swelling. Imaging and histopathological examination confirmed the diagnosis of a thyroglossal duct cyst and a second branchial cleft cyst. The Sistrunk procedure was performed for surgical excision of the masses.

Discussion

Only three cases of a coexisting thyroglossal duct cyst and branchial cleft have been reported.

Conclusion

When encountering patients, even adults, with neck lesions, clinicians must keep in mind the possibility of a coexistence of a thyroglossal duct and a branchial cleft cyst.

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Thyroglossal cysts represent 70% of congenital neck anomalies.

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Second branchial cleft anomalies are the most common branchial apparatus anomalies.

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Only three cases of coexisting thyroglossal duct and branchial cleft cysts have been reported.

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We present a rare case of a young woman with the two cysts coexisting.

Prevalence of cystic metastases in a consecutive cohort of surgically removed branchial cleft cysts

BACKGROUND

Solitary cystic lesion of the neck may often be the only initial presenting symptom for branchial cleft cysts and cystic metastases.

AIMS/OBJECTIVES

To analyse the malignancy rate detected in patients undergoing surgical treatment for lateral branchial cleft cyst.

MATERIAL AND METHODS

The records of all patients with surgical procedure code ENB40 (Excision of lateral branchial cleft cyst- or fistula) between 2003 and 2019 were reviewed. After excluding 150 patients, 436 patients were included for final analysis. Re-evaluation of the cytology including HPV-analysis was performed in those who had a malignant cyst.

RESULTS

Cystic metastases were demonstrated histologically after surgical excision in 13 patients (3%). In patients over 18 years of age, the prevalence of cystic metastasis regardless of the primary tumour type was 3.3%.

CONCLUSION AND SIGNIFICANCE

When the investigation protocol for solitary cystic lesions of the neck is followed, the negative predictive value for malignancy is 97%. All adult patients with a cytologic verified diagnosis of branchial cyst should be examined with HPV-analysis of the cystic sample before excision of the cyst. Failure of predicting a malignancy is often associated with cytology of poor cellularity which may be improved by more frequent use of ultrasound guided fine-needle aspiration cytology (FNAC).

Branchial Cleft Cyst Harbors Metastatic Papillary Thyroid Carcinoma

Branchial cleft cysts are congenital anomalies which develop in utero, most commonly arising from the second branchial cleft. They are often asymptomatic lateral neck masses but can enlarge and become symptomatic in the setting of infection. The cystic cavity can form a potential space which can harbor infection and, in rare cases, malignant spread of primary tumors. Herein, we present a rare case of a 28-year-old male with an enlarging branchial cleft cyst of six months duration following an upper respiratory infection. Routine post-surgical histopathological examination of the excised mass revealed metastatic papillary thyroid carcinoma. To our knowledge, this case is one of five cases reported within the primary literature. This case draws attention to the occult nature of papillary thyroid carcinoma and the importance of routine histopathological examination of seemingly benign surgically excised lesions.

Unusual Isolated Parapharyngeal Second Branchial Cleft Cyst: A Case Report and Literature Review

Second branchial cleft cysts (BCCs) are common congenital causes of neck swellings; however, isolated parapharyngeal space presentation is extremely rare, with only sporadic cases reported. Our objectives in this report are to describe a case and review different diagnostic and management strategies adopted in the current world literature. The case presented is a 26-year-old female with a large isolated parapharyngeal BCC extending to skull base in which first presenting symptoms were referred otalgia and painful side-to-side head rotation for months followed by odynophagia. A previously ordered computed tomography (CT) scan suspected a parapharyngeal abscess. Correct diagnosis was preoperatively achieved using magnetic resonance imaging (MRI) showing a 3.1 × 3.4 × 5.4 cm parapharyngeal BCC. Cyst was completely surgically excised transoral without complications. No evidence of recurrence has been noted after 24-month follow-up. A comprehensive world literature search for all reported cases in the last 30-years revealed thirty cases in 23 separate case reports with different diagnostic and surgical modalities adopted. Presentation and management strategies in such rare cases are discussed in detail. Our study shows that although rare, BCC diagnosis should be kept in mind while dealing with isolated parapharyngeal space swellings with MRI being key for successful preoperative diagnosis. If encountered, the transoral route can be a safe, aesthetically pleasing and effective way for complete surgical excision in contrast to most other parapharyngeal swellings, which are usually better excised via a transcervical approach.

Branchial Cysts in Quito, Ecuador

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.

Resection of Second, Third, and Fourth Branchial Cleft Anomalies with Recurrent or Repeated Neck Infection Using the Selective Neck Dissection Technique

PURPOSE

To explore the applied value of the selective neck dissection to treat second, third, and fourth branchial cleft anomalies with recurrent or repeated neck infections.

METHOD

We made a retrospective study about 29 patients with the second, third, and fourth branchial cleft anomalies with recurrent or repeated neck infections who were treated by surgery from 2002 to 2018 in Sichuan Province Cancer Hospital. According to the characteristics of branchial cleft anomaly on embryology and anatomy, different types of selective neck dissection were chosen to remove pathological scar tissue or inflammatory tissue en bloc.

RESULT

Of 29 cases, 28 had primary healing, and 1 had local infection, healing after dressing change for a long time. In 1 case, branchial cleft anomalies adhered to the internal jugular vein, which was ruptured and sutured. During the follow-up time of 12∼195 months with an average of 91.76 months, there were no recurrent cases.

CONCLUSION

The selective neck dissection technique is safe and effective in the treatment of branchial cleft anomalies with recurrent or repeated neck infection.

Solitary cystic metastatic lymph node of occult human papillomavirus-related oropharyngeal cancer mimicking second branchial cleft cyst: A case report

RATIONALE

Human papillomavirus (HPV)-related oropharyngeal cancer is becoming more common, the primary cancer AQ4 usually occult and appearing only as cystic cervical lymph node (LN) metastasis. Distinguishing between a benign cystic lesion and cystic LN metastasis is challenging given their similar radiologic and histologic appearances.

PATIENT CONCERNS

A 54-year-old man presented with a bulging cystic mass measuring 6.4cm on the right side of neck.

DIAGNOSES

Postexcision diagnosis was second branchial cleft cyst. After 2 years, the cystic mass recurred, and HPV-related tonsillar squamous cell carcinoma with cystic metastatic LNs was confirmed after wide tonsillectomy and neck dissection. The previous cystic lesion proved to be a cystic metastatic LN from the same malignancy with additional p16 immunostain.

INTERVENTIONS

The patient was treated with adjuvant concurrent chemoradiation therapy.

OUTCOMES

The patient was followed up in the outpatient department with no evidence of recurrence after 1 year.

LESSONS

When an adult has a cystic mass in the upper neck, we must rigorously exclude it as a cystic metastatic LN of occult HPV-related oropharyngeal cancer. Additional p16 staining might be helpful.

CT and MR imaging findings of infection-free and benign second branchial cleft cysts

PURPOSE

The present study aimed to assess CT and MR imaging findings of infection-free and benign second branchial cleft cysts (SBCCs).

METHODS

Eleven patients with histopathologically confirmed infection-free and benign SBCCs underwent preoperative contrast-enhanced CT (CECT) and/or MR imaging. We assessed qualitative (presence and extent of wall thickening, degree of contrast enhancement of the thickened wall on CECT images, and signal intensity of the thickened wall on T2-weighted images) and quantitative (maximum thickness of the thickened wall) imaging findings.

RESULTS

Eccentric and smooth wall thickening was observed in 11/11 (100%) patients. The wall thickening extent (percentage of the thickened wall to the circumference of the wall) was small (1%-25%) in 4/11 (36%), moderate (26%-50%) in 6/11 (54%), extensive (51%-75%) in 1/11 (9%), and diffuse (76%-100%) in 0/11 (0%) patients. Mild homogeneous enhancement of the thickened wall on CECT images was observed in 7/7 (100%) patients. The signal intensity of the thickened wall on T2-weighted images was isointense relative to that of normal lymph nodes in 7/8 (88%) and mildly hyperintense in 1/8 (12%) patient. The maximum thickness of the thickened walls ranged from 2 to 4 (mean 3.4) mm.

CONCLUSIONS

Infection-free and benign SBCCs are identifiable as cysts with eccentric and smooth wall thickening on CECT and MR images. The wall thickness was almost always less than half of the wall circumference, isointense relative to normal lymph nodes, and showed mild homogeneous enhancement.

Human papillomavirus (HPV) is absent in branchial cleft cysts of the neck distinguishing them from HPV positive cystic metastasis

BACKGROUND

Distinguishing branchial cleft cysts (BCCs) from cystic metastases of a human papillomavirus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC) is challenging. Fine needle aspirates (FNAs) from cystic metastasis may be non-representative, while reactive squamous cells from BCC can be atypic. Based on cytology and with the support of HPV DNA positivity many centers treat cystic metastasis oncological and thus patients are spared neck dissection. To do so safely, one must investigate whether HPV DNA and p16^INK4a overexpression is found exclusively in cystic metastases and not in BCC.

PATIENTS AND METHODS

DNA was extracted from formalin fixed paraffin embedded (FFPE) surgically resected BCCs from 112 patients diagnosed 2007-2015 at Karolinska University Hospital and amplified by PCR. A multiplex bead-based assay used to detect 27 HPV-types and p16^INK4a expression was analyzed by immunohistochemistry (IHC).

RESULTS

All 112 BCCs were HPV DNA negative, and of 105 BCCs possible to evaluate for p16^INK4a, none overexpressed p16^INK4a.

CONCLUSIONS

HPV DNA and p16^INK4a overexpression were absent in BCCs. Lack of HPV DNA and p16 protein overexpression in BCCs is helpful to discriminate benign BCCs from HPV⁺ OPSCC metastasis. HPV testing definitely has a role in the diagnostics of cystic masses of the neck.

The incidence of malignancy in clinically benign cystic lesions of the lateral neck: our experience and proposed diagnostic algorithm

AIM

Solitary cystic masses of the lateral neck in an adult patient can pose a diagnostic dilemma. Malignancy must be ruled out since metastases arising from H&N cancers may mimic the presentation of benign cystic masses. Only a small number of studies have investigated the diagnostic management and malignancy rate of clinically benign solitary cervical cystic lesions. There are no established guidelines for the diagnostic evaluation.

METHODS

Retrospective review of the clinical, cytological, radiological, and pathological records of all adult patients (> 18 years) operated on for second branchial cleft cysts (BrCC) between 1/2008-2010/2016. Patients with apparent primary H&N malignancy, history of H&N cancer or irradiation, preoperative fine needle aspiration (FNA) of highly suggestive or confirmed malignancy, missing pertinent data, or age less than 18 years were excluded from analysis.

RESULTS

28 patients were diagnosed as having BrCC. The diagnosis was based on clinical findings, FNA cytology, and typical sonographic features. The histologic analysis determined an overall rate of malignancy of 10.7% (3/28): two patients had metastatic papillary thyroid carcinoma, and one patient had metastatic tonsillar squamous cell carcinoma. Purely cystic features on pre-operative ultrasound was the only significant predictor for true BrCC on final histology (p = .02).

CONCLUSIONS

Occult malignancy is not rare among adult patients presenting with a solitary cystic mass of the lateral neck. A diagnostic algorithm is proposed. Further studies are needed to establish the appropriate workup and management of an adult patient presenting with a solitary cystic mass of the lateral neck.

Unusually rapid development of a lateral neck mass: Diagnosis and treatment of a branchial cleft cyst. A case report

Introduction

Branchial cleft cysts are benign lesions caused by anomalous development of the branchial cleft. Cases that arise in the lateral neck region are often misdiagnosed, resulting initially in inappropriate management.

Case presentation

We describe a 32-year-old woman with a swelling on the right side of her neck and no pain during palpation or neck motion.

Discussion

The patient was evaluated using fine-needle aspiration cytology (FNAC), ultrasound, and magnetic resonance imaging (MRI) scans. The MRI showed a right-sided cervical mass with hyperintense content, well-defined margins, and no evidence of infiltration into surrounding structures, while FNAC found a yellow, pus-like fluid, keratinised anuclear cells, squamous epithelium, and a matrix of amorphous debris.

Conclusion

Based on the images and the patient's symptoms, a surgical intervention was performed.

Lymphoepithelial Cyst in the Palatine Tonsil

Lymphoepithelial cyst (LEC) is the most commonly encountered congenital neck pathology in the lateral part of the neck. A 66-year-old woman presented to the ENT clinic due to difficulty in swallowing persisting for approximately 1 year. Magnetic resonance imaging revealed a cystic mass at right tonsil. Surgery was performed due to this unilateral tonsillar mass, which was excised together with the right tonsil. LEC was diagnosed at histopathological examination. LEC in the palatine tonsil is rare, and only a few cases have been reported in the literature. We report a rare case of LEC in the palatine tonsil.

Branchial cleft and pouch anomalies in childhood: a report of 50 surgical cases

BACKGROUND AND AIMS

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.

METHODS

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.

RESULTS

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 %.

CONCLUSIONS

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.