Branchial cleft cyst: A rare diagnosis in a 91-year-old patient

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.

Differential diagnosis of cystic neck lesions

OBJECTIVES

In patients less than 40 years of age who present with an upper anterior triangle cystic mass, branchial cyst is the presumed clinical diagnosis. Squamous cell malignancy is the important differential diagnosis in a patient more than 40 years of age. We sought to identify the range of lesions that can be clinically mistaken for, and removed as, branchial cysts.

METHODS

We performed retrospective reviews of 29 neck masses removed as branchial cysts and 47 solitary neck masses diagnosed as cancer between January 2003 and January 2008 across two teaching hospitals in Leeds, England.

RESULTS

Of the 29 lesions removed, 23 (79.3%) were confirmed to be branchial cysts. The remainder comprised 2 thyroid papillary carcinomas (6.9%) and 4 benign lesions (13.6%; laryngocele, neurilemmoma, parotid gland cyst, and cystadenoma). Of the 47 cases of metastatic cancer, 3 lesions (6.4%) were clinically mistaken as branchial cysts but were subsequently diagnosed as squamous cell carcinomas.

CONCLUSIONS

When presented with a solitary lateral cystic mass, clinicians should consider the possibility of squamous cell carcinoma in patients more than 40 years of age, and thyroid papillary cancer should be considered particularly in the younger age groups. In our series, 30.8% of the neck lesions believed to be branchial cysts in patients over 40 were malignant, in contrast to 5.3% of those lesions in patients under 40.

Branchial remnant cysts of mature and juvenile horses

This clinical report describes 8 cases of branchial remnant cysts (BRC) in the horse. The horses presented with bimodal age distribution, with 5 cases in mature horses (age 8-21 years) and 3 in foals (age 1, 6 and 10 months). Mature cases presented for dysphagia or intermittent oesophageal obstruction (2/5), and retropharyngeal swelling (3/5), whereas respiratory stridor and visible mass were presenting complaints in the foals. Presence of a right-sided (5/8) or dorsally located (2/8) palpable retropharyngeal mass of 3-35 cm diameter was noted clinically; one left-sided mass was identified as an incidental finding at necropsy. Ultrasonography typically revealed a thick-walled cyst containing hypoechoic fluid with dependent hyperechoic masses consistent with blood clots. Radiographs and upper airway endoscopy were also consistent with a retropharyngeal mass. Fluid cytology revealed chronic haemorrhage in 6/8 cases, and squamous epithelial cells in one case. Histopathology in all cases demonstrated an epithelium-lined cyst with no smooth muscle or thyroid tissue. Two cases was subjected to euthanasia; one due to concurrent laryngeal anomalies and one due to financial constraints. The remaining 5 cases were treated via surgical excision. Post operatively, right laryngeal hemiplegia was observed in 4/5 cases. All previous reports of BRC in the horse have described juvenile individuals. Brachial remnant cyst should be considered a differential diagnosis for mature horses with masses of the throatlatch area and can be definitively diagnosed by the presence of squamous epithelium in aspirated fluid or by histopathology of the excised mass. Right recurrent laryngeal nerve damage is a common complication of surgery.