Second branchial cyst in the parapharyngealspace: a case report

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.

Contemporary Management of Benign Parapharyngeal Lesions Using Minimally Invasive Techniques: Case Discussion and Review of the Literature

Branchial anomalies can present in the parapharyngeal space, creating unique challenges in management. Historically, this approach warranted an open approach, including transcervical, transparotid with total parotidectomy and retromandibular dissection, or transmandibular dissection with mandibulotomy. However, the advent of minimally invasive transoral techniques and laser resection have allowed for successful resection of masses in this anatomical region without an external approach. We illustrate these advancements with the case of a 30-year-old man with globus sensation and throat discomfort, found to have a mass of the right posterolateral oropharynx causing severe airway obstruction. Imaging showed a parapharyngeal mass with extension to the carotid sheath and retropharyngeal space, which was successfully resected with potassium-titanyl-phosphate (KTP) laser using a minimally invasive transoral approach with no major complications. Transoral excision offers decreased morbidity and a cosmetically favorable outcome compared to transcervical excision. KTP laser may be safely used for transoral excision of a benign parapharyngeal mass.

Pediatric parapharyngeal lesions: criteria for malignancy

INTRODUCTION

Parapharyngeal space (PPS) pediatric lesions represent a heterogeneous group of uncommon neoplasms of both benign and malignant nature. These tumors tend to be locally advanced by the time they are diagnosed; consequently, an early presumptive diagnosis of malignancy is of utmost importance.

OBJECTIVE

To highlight the occurrence of malignant PPS tumors in pediatric population, to determine their incidence and to describe probable warning clues for diagnosis.

PATIENTS AND METHODS

The charts of 23 pediatric patients with PPS swellings were retrospectively reviewed to analyze clinical and pathologic data. We describe possible criteria to suspect malignancy by clinical and radiological examination.

RESULTS

Twenty-three patients presented with neoplastic lesions in the PPS, benign tumors in 43.5% and malignant in 56.5%. Malignancy was suspected in 13 cases according to combined clinical and radiological criteria: a painless intraoral and neck swelling in children below one year old, presentation with cranial nerve palsy, nasopharyngeal mucosal or sub-mucosal irregular lesion, the presence of multiple lymph nodes with no evidence of infection, and adjacent bony skull base destruction with intracranial extension.

CONCLUSION

Occurrence of malignancy in PPS tumors in the pediatric population is not uncommon. Clinicians should deliberately look for associated secondary signs that predict malignancy. The surgeon must understand the pathological spectrum of tumors of this space and the proper use of imaging studies to make a preoperative diagnosis. This allows for planning of a sound surgical approach and a proper preoperative counseling.

Atypical imaging observations of branchial cleft cysts

The aim of the present study was to assess the atypical imaging manifestations of branchial cleft cysts (BCCs) confirmed by pathology. Computerized tomography (CT) or magnetic resonance imaging (MRI) of 17 BCC cases were reviewed. The imaging features, including laterality, location, border, attenuation and internal architecture, were evaluated. All 17 cases were second BCCs, including 5 cases of Bailey type I classification cysts and 12 cases of type II classification cysts. The atypical imaging features included signal and morphological abnormalities. The abnormal signal intensities were caused by intracapsular bleeding (n=2) or solidification of cystic fluid (n=2). Intracystic hemorrhaging revealed homogeneous hyperintensity on T1-weighted image (T1WI) and T2-weighted image (T2WI). Solidification of cystic fluid revealed slightly homogeneous hyperintensity compared with muscle on T1WI and homogeneous hypointensity on T2WI without enhancement. The aberrant morphology mainly presented as thickening of the cystic wall (n=13). Thickened walls of BCCs with ill- (n=5) or well- (n=8) defined borders were observed in 13 patients. In 3 patients, significant enhancement was identified following intravenous gadolinium administration (n=4). When with atypical CT or MRI features are presented, the typical location of BCCs can help in the diagnosis, as it is located at the lateral portion of the neck adjacent to the anterior border of the mandibular angle or sternocleidomastoid muscle. The atypical observations, including variable signals, imply that the cystic content has changed. Thickened walls indicate inflammation or cancerous tendency and patients with ill-defined margins, vascular involvement or lymphadenopathy atelectasis indicate malignant conversion.