Unusual coexistence: branchial cleft cyst harboring papillary thyroid carcinoma with lymph node metastasis - a rare case report and clinical insights

Background

The simultaneous occurrence of Branchial Cleft Cyst (BCC) and Papillary Thyroid Carcinoma (PTC) represents an unusual malignant tumor, with cases featuring associated lymph node metastasis being particularly rare. This combination underscores an increased potential for metastasis, and the assessment of neck masses, particularly on the lateral aspect, may inadvertently overlook the scrutiny of the thyroid. Therefore, healthcare providers should exercise vigilance, especially in patients over the age of 40, regarding the potential for neck masses to signify metastasis from thyroid malignancies. Currently, surgical intervention stands as the primary effective curative method, while the postoperative administration of radioactive iodine therapy remains a topic of ongoing debate.

Case report

In the presented case, a 48-year-old male patient with a right neck mass underwent surgical intervention. The procedure included the excision of the right neck mass, unilateral thyroidectomy with isthmus resection, and functional neck lymph node dissection under tracheal intubation and general anesthesia. Postoperative pathology findings revealed the coexistence of a BCC with metastatic PTC in the right neck mass, as well as papillary carcinoma in the right thyroid lobe. Lymph node metastasis was observed in the central and levels III of the right neck.

Conclusion

The rare amalgamation of a BCC with PTC and concurrent lymph node metastasis underscores the invasive nature of this malignancy. Healthcare professionals should be well-acquainted with its clinical presentation, pathological characteristics, and diagnostic criteria. A multidisciplinary approach is strongly recommended to enhance patient outcomes.

Respiratory distress in a neonate: Inflation of a third branchial anomaly with positive airway pressure

Positive airway pressure from noninvasive ventilation is an essential tool for many pediatric patients with respiratory distress. We present a case of an unknown third branchial anomaly that was diagnosed following inflation with continuous positive airway pressure (CPAP), which exacerbated the infant's respiratory distress.

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.

A Rare Presentation of a Branchial Cleft Cyst: Can It Cause Syncope in a Pediatric Patient?

Branchial cleft cysts (BCCs) are a congenital malformation most commonly seen in children and adolescents. BCCs are usually incidental findings and are benign in nature. In this report, we present a case of a 13-year-old female with syncope as a rare complication of a fluid-filled second BCC. The patient initially presented with a unilateral non-tender swelling on the right side of the neck and submandibular region, which was suspicious of an inflammatory process. After initial lab investigations came back negative, imaging studies of the neck with computed tomography (CT) with intravenous contrast revealed a hypodense lesion with a uniform density, which lay beneath the sternocleidomastoid muscle and abutted the carotid sheath. The cyst was surgically excised, and histopathological studies of the cyst wall and the analysis of the fluid contained within the cyst confirmed that it was indeed a branchial cleft cyst. We propose that the syncopal episodes she experienced most likely occurred due to the proximity of the cyst wall to the carotid sheath, which caused a mass effect leading to carotid sinus syndrome (CSS). This is the first case of CSS due to a BCC to be reported in the pediatric population.

Pediatric Neck Swelling: A Case Report of Fourth Branchial Cleft Cyst

Pediatric neck masses present a diagnostic challenge, encompassing various etiologies, including rare entities like branchial cleft anomalies. Branchial cleft cysts, resulting from incomplete embryonic cleft obliteration, may become symptomatic. This case report describes a seven-year-old boy who presented with a week-long history of fever and progressively enlarging left anterior cervical swelling. Physical examination revealed a fluctuant, non-tender mass, prompting diagnostic investigations. Laboratory results indicated an elevated white blood cell count and inflammatory markers. Computed tomography identified a hypodense, rim-enhancing mass consistent with an abscess secondary to a fourth branchial cleft cyst. Ultrasound-guided aspiration yielded purulent material, confirming Staphylococcus aureus infection. This case highlights the clinical significance of fourth branchial cleft cysts as rare inflammatory neck masses in pediatric patients. The embryological context informs their diverse anatomical manifestations. Surgical excision remains the primary treatment, demanding consideration of anatomical complexities.

Ectopic Salivary Gland - A Possible Differential Diagnosis of a Branchial Cleft Cyst

Background: Branchial cleft cysts or fistulae are common in pediatric surgical pathology and are cured by surgery. Lesions in this area may not show the classical features of a cyst or duct lined by squamous or respiratory epithelium and other differential diagnoses should be considered. Case report: A seven-year-old otherwise healthy boy presented with bilateral swelling of the lower neck and reported intermittent secretion of clear fluid on the right side. Excision of the right sided lesion revealed an ectopic salivary gland, the excision of the left showed only subtle fibrosis. Conclusion: Ectopic salivary glands may occur in the distribution of branchial cleft remnants. Clear fluid drainage (saliva) may be a clinical clue that these are not branchial cleft cremnants.

Excision of massive left branchial cleft cyst with secondary hypertension

Branchial anomalies are heterogeneous congenital malformations that form secondary to incomplete closure of pharyngeal clefts and pouches. There have been no reports of branchial cleft cysts causing carotid artery compression and hypertension. We report a large branchial cleft cyst causing suspected secondary hypertension from carotid artery compression.

[Malignant transformation of a branchial cleft cyst]

Branchial cleft cyst is the most common birth defect involving the neck. Malignant transformation is known, however, differentiating from a neck metastasis of a squamous cell carcinoma of unknown primary is challenging. Even though there are strict criterias, the diagnosis of this entity remains controversial. We present the case of a 69-year-old woman, who presented with a swelling under the left side of the mandible. After diagnostic workup, fine-needle aspiration biopsy raised the suspicion of a cystic squamous cell carcinoma metastasis, therefore we performed panendoscopy and modified radical neck dissection. The pathological examination confirmed branchial cleft cyst carcinoma. After surgery, the patient received adjuvant radiation and chemotherapy. During the case workup, we present the difficulties of the diagnostic process, differential diagnostic problems, and the review of the international literature. In the case of a solitary, cystic mass on the neck without a primary tumor, we should consider the possibility of a branchiogenic carcinoma. Orv Hetil. 2023; 164(10): 388-392.

Fourth Branchial Cleft Cyst: An Important Differential Diagnosis in Lateral Neck Masses

Branchial anomalies are a result of abnormal development during embryogenesis and are a rare cause of lateral neck masses of congenital origin. The second branchial cleft is the most common site of origin, with abnormalities arising from the first, third, and fourth clefts being rarer. Although cysts originating from branchial clefts are infrequent, it is important to consider this pathology in the differential diagnosis of neck masses, particularly those located laterally. This article discusses a rare case of a 49-year-old female patient who presented with the sudden appearance of a lateral neck mass after sports practice. The patient underwent extensive diagnostic studies, including radiological studies, which were compatible with a fourth branchial cleft cyst. The patient remains asymptomatic, and possible surgical treatment is being evaluated by the head and neck surgery service. This clinical case highlights the importance of prompt diagnosis and appropriate management of rare pathologies such as branchial cleft cysts.

Complications and Diagnosis of Branchial Cleft Cysts: A Case Report

Branchial cleft cysts (BCCs) are congenital anomalies that can be found in children and young adults. The exact incidence of these anomalies is unknown as the diagnosis may be missed. Branchial cleft cysts can present in a variety of locations depending on the cleft they are derived from. Regardless of location, branchial cleft cysts are rather benign. However, a variety of complications can arise due to infection, and infections are often recurrent. Diagnosis may occur incidentally on imaging studies as such studies are often performed to rule out a variety of complications from infections alone. Treatment includes first treating any infection and any such complications that exist, followed by surgical excision. Surgical excision is performed to prevent the recurrence of infection. A case of a 14-year-old female with a painful swollen throat, trismus, and difficulty swallowing is reported.

An Uncustomary Branchial Cleft Cyst Presentation With Associated Autoimmune Thyroiditis

Branchial cleft cyst is an embryogenic anomaly of branchial apparatus usually occurring in the lateral aspect of the neck. Very few cases of intrathyroidal cystic lesion of branchial cleft have been reported in English literature so far. The patient was a 42-year-old female who presented to the Otorhinolaryngology department with anterior neck mass. The serology revealed elevated antibodies to thyroglobulin and thyroid peroxidase. Fine needle aspiration done in an outside hospital was reported as an epidermal inclusion cyst. Radiology examination of the neck was suggestive of infected fourth branchial cleft cyst. Left hemithyroidectomy was done. On histopathology examination, branchial cleft cyst within the thyroid parenchyma exhibiting features of autoimmune thyroiditis and secondary degenerative changes was noted. This rare case is reported to emphasize multiple-site fine needle aspiration in heterogenous thyroid lesions along with radiological correlation for correct diagnosis and appropriate treatment.

Identification of a branchial cleft anomaly via handheld point-of-care ultrasound

Aim of the study

Branchial anomalies result from incomplete obliteration of the branchial arch structures during embryogenesis. Second branchial arch anomalies are commonly found on the lower third of the neck, with an opening at the anterior border of the sternocleidomastoid muscle, and may drain secretions or purulent material. This case demonstrates the use of handheld point-of-care ultrasound to aid in the diagnosis of a branchial anomaly.

Case description

The patient presented with a “hole” in the neck with intermittent drainage from the site. A 2 mm defect in the skin was noted anterior to the sternocleidomastoid muscle. A handheld ultrasound system was used to identify a well-defined, hypoechoic, cyst-like structure. Given the history, physical findings, and point-of-care ultrasound imaging, the diagnosis of a second branchial cleft sinus was made.

Conclusions

The use of point-of-care ultrasound and knowledge of the sonographic characteristics of these lesions can assist the physician in the diagnosis of branchial arch anomalies.

Intraoral Approach for Parapharyngeal Branchial Cleft Cysts

Branchial cleft cyst (BCC) most frequently arises from the second branchial cleft and is located anterior to the sternocleidomastoid muscle at the mandibular angle. However, very rarely, this may occur in the parapharyngeal space. Interestingly, the parapharyngeal BCC is frequently misdiagnosed as a peritonsillar abscess. In this study, we reported 2 cases of parapharyngeal BCC misdiagnosed as peritonsillar abscess.

First Branchial Cleft Anomalies: Awareness Is Key

Two patients presented with fluctuant areas inferior to the pinna. The first required numerous procedures and investigations before a correct diagnosis was obtained. However, with awareness of this condition, the subsequent patient was quickly identified and managed appropriately. First branchial cleft abnormalities are uncommon, however, present with common symptoms. Their location and characteristics in paediatric patients is key to having it in the differential diagnosis. Consideration of this condition by ENT surgeons is key to prevent multiple invasive and futile operations in our paediatric cohort.

Chronic Lateral Neck Mass in an Adolescent Female

Neck masses are a common finding in the pediatric population, with a broad differential diagnosis resulting in real diagnostic challenges. They are most frequently caused by reactive lymphadenopathy, infectious lymphadenitis, or congenital anomalies of the neck. This case report describes a 16-year-old female presenting to the pediatric emergency department with 5 weeks of right-sided neck mass. Based on her history, physical examination, and prolonged clinical course, the differential diagnosis included infectious, congenital, and neoplastic causes. The patient was ultimately diagnosed with a branchial cleft cyst and referred to a pediatric head and neck surgeon.

Inflammatory or malignant? Lessons from a cystic lateral neck lesion with a sudden onset

Összefoglaló. A lateralis cysticus nyaki terimék két leggyakoribb oka a branchiogen cysta és a cysticus nyaki áttét. Az átfedő lokalizáció (a leggyakrabban a IIA nyaki régióban), a betegek életkora és az esetenként hirtelen kezdet alapján a két leggyakoribb ok differenciáldiagnózisa nagy kihívást jelenthet. Egy hirtelen fellépő fájdalmas, bal oldali nyaki duzzanattal, dysphagiával és lázzal jelentkező 72 éves férfi esetét ismertetjük. A nyak komputertomográfiás vizsgálata egy 6 cm legnagyobb átmérőjű, vastag falú, többrekeszes cysticus terimét igazolt. Infektív branchiogen cysta lehetőségére gondolva az elváltozást eltávolítottuk. A szövettan azonban p16-pozitív laphámrákot igazolt. A primer tumort végül az ipsilateralis tonsilla palatina állományában sikerült azonosítani. A beteg definitív radioterápiában részesült, és 18 hónappal a diagnózis után tumormentes. A nyaki cystákon, az infektív nyaki cystákon és a cysticus metastasisokon kívül a humán papillómavírussal összefüggő szájgarati laphámrákok infektív cysticus vagy necroticus metastasisait is figyelembe kell venni a lateralis cysticus nyaki terimék differenciáldiagnózisában. Orv Hetil. 2020; 162(15): 595-600. Summary. Branchial cleft cysts and cystic neck metastases are the two most common causes of cystic lateral neck masses. Based on the overlapping location (neck level IIA), patient age at onset and the occasionally sudden onset, their differential diagnosis is challenging. We present a 72-year-old male presenting with a suddenly emerging painful, left-sided neck swelling, dysphagia and fever. Computed tomography showed a 6 cm thick-walled multicystic mass. With the suspected diagnosis of an infected branchial cleft cyst, the lesion was removed. Histology confirmed p16 positive squamous cell carcinoma. Primary tumor was identified in the ipsilateral palatine tonsil. Definive radiotherapy was performed and the patient is free of disease at the 18-month follow-up. Beyond pure and infected branchial cleft cysts and pure cystic metastases, infected cystic or necrotic metastasis of human papillomavirus associated oropharyngeal squamous cell carcinoma should be included in the differential diagnosis of cystic lateral neck lesions. Orv Hetil. 2021; 162(15): 595-600.

Sclerotherapy for Benign Cystic Lesions of the Head and Neck: Systematic Review of 474 Cases

OBJECTIVE

The role of sclerotherapy for vascular lesions of the head and neck is well established. However, the efficacy of sclerotherapy for benign cystic lesions of the head and neck is less clear. The objective of this review is to determine the efficacy and safety of sclerotherapy for benign cystic lesions of the head and neck.

DATA SOURCES

PubMed/MEDLINE, Cochrane Library, and Embase.

REVIEW METHODS

The PRISMA guidelines (Preferred Reporting Systems for Systematic Reviews and Meta-analyses) were followed for this systematic review. Studies of patients with benign head and neck cystic masses treated primarily with sclerotherapy were included. Thirty-two studies met criteria for inclusion.

RESULTS

A total of 474 cases of sclerotherapy were reviewed. Agents comprised OK-432, ethanol, doxycycline, tetracycline, and bleomycin. Lesions in the analysis were ranula, thyroglossal duct cyst, branchial cleft cyst, benign lymphoepithelial cyst, parotid cyst, thoracic duct cyst, and unspecified lateral neck cyst. A total of 287 patients (60.5%) had a complete response; 132 (27.9%) had a partial response; and 55 (11.6%) had no response. OK-432 was the most widely utilized agent, with a higher rate of complete response than that of ethanol (62.0% vs 39.4%, P = .015). Fifty-three cases (11.2%) required further surgical management. One case of laryngeal edema was reported and managed nonoperatively.

CONCLUSION

Sclerotherapy appears to be a safe and efficacious option for benign cystic lesions if malignancy is reliably excluded. Efficacy rates are comparable to those of sclerotherapy for vascular malformations. The rate of serious complications is low, with 1 incident of airway edema reported in the literature.

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.

Lateral neck cyst as initial presentation of thyroid malignancy

INTRODUCTION

A mass in the lateral aspect of the neck may cause a diagnostic dilemma for the clinician. Cystic lateral neck masses in young adults are most often benign as the most frequent cause is a branchial cleft cyst. However, this may be a pitfall as such a cystic mass can be a first presentation of occult malignancy.

CASE REPORT

Here we present a case of a 25-year-old female patient with a cystic mass in the right lateral neck. This lesion was eventually diagnosed as cystic degeneration within a metastatic invaded lymph node from papillary thyroid carcinoma. Total thyroidectomy with right central and lateral lymphadenectomy was performed.

DISCUSSION

The correct diagnosis risked to be missed as the initial appearance was mimicking a benign branchial cleft cyst.

CONCLUSION

We aimed to highlight the possibility of an underlying unsuspected thyroid carcinoma in young patients initially presenting with a neck mass mimicking the more common benign branchial cleft cyst. We underline the necessity of thoroughly examining suspected cysts as adequate diagnosis should avoid delayed treatment as it directly affects the tumor stage and prognosis.

Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes

OBJECTIVE

Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present.

METHODS

A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected.

RESULTS

A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases.

CONCLUSION

A combination approach to fourth branchial apparatus lesions-including endoscopic cauterization, external excision, and hemithyroidectomy-is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

Three unusual parapharyngeal space masses resected via the endoscopy-assisted transoral approach: case series and literature review

Tumors of the parapharyngeal space (PPS) are rare, most originate from salivary and neurogenic tissues, and most are benign. However, there are some rarer masses in the PPS, with just a few published reports in the literature worldwide, and we may not consider them in the differential diagnosis of PPS neoplasms. We report three cases of rare masses in the PPS: Warthin’s tumor, branchial cleft cyst, and carcinoma ex pleomorphic adenoma. The three patients were admitted to our department with complaints of painless swelling in the lower side of the right face or a long history of snoring; diagnoses were confirmed histopathologically. An endoscopy-assisted transoral approach was used that allowed wide visibility for safe resection and resulted in a short hospitalization time and good functional and cosmetic outcomes. All patients have been followed to the current time, and there have been no recurrences. The transoral endoscopy-assisted approach appears to be safe, effective, and less invasive for excision of masses in the PPS.

Postoperative Outcomes of Branchial Cleft Cyst Excision in Children and Adults: An NSQIP Analysis

OBJECTIVE

Identify risk factors and perioperative morbidity for patients undergoing branchial cleft cyst (BCC) excision.

STUDY DESIGN

Cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases (NSQIP and NSQIP-P).

SUBJECT AND METHODS

Patients who underwent BCC excision (Current Procedural Terminology 42810, 42815) were queried via NSQIP (2005-2016) and NSQIP-P (2012-2016). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of hospital stay, postoperative complications, and readmission.

RESULTS

A total of 1775 children and 677 adults were identified. Mean age at time of surgery was 4.6 years for children and 38.6 years for adults. Outpatient procedures were performed in 87.1% of adults and 94.0% of children (P < .001). Postoperative complications were uncommon, occurring in <1% of adults and 3.9% of children (P < .001). Similarly, readmission occurred in 1.2% of adults and 1.1% of children. In adults, smoking status was shown to have a significant effect on postoperative complications (odds ratio, 6.25; P = .037). Age group did not have an effect on the complication rate in the pediatric population. Pediatric otolaryngologists had higher rates of postoperative complications (P = .001), prolonged operative times (P < .001), and fewer outpatient procedures (P < .001). Conversely, in adults, otolaryngologists had fewer postoperative complications.

CONCLUSION

Postoperative complications following BCC excision are relatively uncommon, demonstrating procedural safety when performed at any age.

Radiologic Features of Papillary Carcinoma in the Second Branchial Cleft Cyst

Clinically, it may be very difficult to differentiate between benign branchial cleft cyst (BCC) and malignant BCC with papillary carcinoma preoperatively. Radiological features were reviewed retrospectively between benign BCC and malignant BCC with papillary carcinoma using computed tomography (CT) and magnetic resonance (MR) images. All patients had only a mass on the right upper lateral neck without lesion in the thyroid gland. Two patients had a mass in the upper medial part of BCC on CT images and one patient showed a well-circumscribed mass in the upper portion of BCC on MR image. Two patients received BCC removal only and one patient underwent total thyroidectomy including removal of BCC. As results, most cases of papillary carcinoma in the BCC were detected incidentally after surgical resection of BCC. However, we can differentiate between benign BCC and malignant BCC with primary papillary carcinoma by carefully reviewing radiologic images before surgery.

Bilateral Ear Canal Cholesteatoma with Underlying Type I First Branchial Cleft Anomalies

OBJECTIVES:

To describe a case of bilateral ear canal cholesteatomas in the setting of underlying first branchial cleft cyst anomalies and to review the pathophysiology underlying the development of external auditory canal cholesteatomas from branchial cleft cyst abnormalities.

METHODS AND RESULTS:

We present a case study of a 61-year-old man who presented with chronic right-sided hearing loss and left-sided postauricular drainage. Clinical evaluation, radiographic work-up, and pathologic analysis confirmed a diagnosis of bilateral ear canal cholesteatoma in the setting of underlying first branchial cleft cyst anomalies. The patient's clinical course, surgical treatment, and management considerations are discussed here.

CONCLUSION:

Ear canal cholesteatoma represents a rare clinical disease entity deserving a thorough initial assessment. Careful consideration of underlying diseases that result in chronic inflammation, such as branchial cleft lesions, should be included in the differential diagnosis of idiopathic canal cholesteatoma in the absence of prior otologic surgery or trauma.

A unique location of branchial cleft cyst: case report and review of the literature

Branchial cleft cysts (BCC) are benign lesions caused by anomalous development of the branchial apparatus. This case report describes a 63-year-old woman with a 12 cm×12cm sized cystic mass located anterior to the manubrium sternum and sternum. MRI revealed a cystic lesion with a sinus tracking to the piriform sinus. Postoperative histopathological examination confirmed the diagnosis of branchial cleft cyst. Because of the course of the sinus track, it is believed that this was a fourth branchial cleft cyst. These are the rarest of the branchial anomalies, and extension below the peri-thyroid region is very infrequently described. When this extension occurs, it is always post-sternal into the mediastinum, and the pre-sternal presentation here appears to be unique. A review of the relevant literature was performed to summarize the clinical features of fourth branchial cleft cyst and to identify the best options for diagnosis and treatment.

Sonographic diagnosis of coexisting ectopic thyroid and fourth branchial cleft cyst

Ectopic thyroid and fourth branchial cleft anomaly are rare congenital anomalies of the neck. This is a case report of the coexistence of these two rare congenital anomalies in a 1-year-old girl. She had ectopic lingual thyroid and asymptomatic abscess in the fourth branchial cleft cyst, which was found in ultrasonography carried out to evaluate congenital hypothyroidism. To the best of our knowledge, this is the first reported case of ectopic thyroid coexisting with fourth branchial cleft anomaly in the same patient.

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.

Detection of human papillomavirus in branchial cleft cysts

High-risk human papillomavirus (HPV) DNA has been reported to be present in branchial cleft cysts, but further information is required to clarify the role of HPV infection in branchial cleft cysts. The presence of HPV, the viral load and the physical statuses in samples from six patients with branchial cleft cysts were investigated using the polymerase chain reaction (PCR), quantitative PCR, in situ hybridization (ISH) using HPV DNA probes and p16^INK4a immunohistochemical analysis. High-risk type HPV-16 DNA was identified in four of the six branchial cleft cysts analyzed. Of the HPV-positive branchial cleft cysts, three exhibited mixed-type integration of HPV. HPV DNA was distributed among the basal-to-granular layers of the cystic wall in ISH analysis, and p16^INK4a was weakly expressed in the nuclei and cytoplasm of the same layers in patients with integration. ISH revealed that one patient with episomal-type infection exhibited HPV DNA in the cyst wall and did not express p16^INK4a. Two patients without evidence of HPV infection exhibited weak p16^INK4a expression in the superficial cyst-lining cells of branchial cleft cysts. These results indicate that infection with high-risk HPV types may be common in branchial cleft cysts. In addition, p16^INK4a is not a reliable surrogate marker for HPV infection in branchial cleft cysts.

Primary parotid lymphoma presenting as a recurrent cystic mass: A case report

A 15-year-old boy was diagnosed with a cystic parotid mass, which was initially thought to be a first branchial cleft cyst. The mass was treated with antibiotics and fully resolved on examination and imaging. The mass returned, and a superficial parotidectomy was performed to remove the suspected branchial cleft cyst. Final pathology demonstrated a B-cell lymphoblastic lymphoma. Bilateral bone marrow biopsies and peripheral blood counts were negative for any malignancy. This case demonstrates a rare presentation of primary parotid B-cell lymphoblastic lymphoma that began as a fluctuating cystic parotid mass consistent in appearance with a first branchial cleft cyst. Laryngoscope, 128:998-1001, 2018.

Branchial Cleft Cyst

Branchial cleft cyst, sinuses, and fistulae are among the most commonly encountered congenital anomalies in pediatric otolaryngic practice. They can present difficulty in diagnosis and surgical management. Here, I report a case of 14-year-old boy who presented with asymptomatic, congenital swelling located just below the jawline in the lateral part of the neck. The lesion was excised surgically. Histopathology showed the cyst lined by squamous as well as columnar ciliated epithelium, which was a characteristic finding of branchial cleft cyst. The aim of presenting this case is its rarity.

Neonatal Presentation of an Air-Filled Neck Mass that Enlarges with Valsalva: A Case Report

Branchial cleft cysts are common causes of congenital neck masses in the pediatric population. However, neonatal presentation of branchial cleft cysts is uncommon, but recognizable secondary to acute respiratory distress from airway compression or complications secondary to infection. We report a 1-day-old infant presenting with an air-filled neck mass that enlarged with Valsalva and was not associated with respiratory distress. The infant was found to have a third branchial cleft cyst with an internal opening into the pyriform sinus. The cyst was conservatively managed with endoscopic surgical decompression and cauterization of the tract and opening. We review the embryology of branchial cleft cysts and current management.

Bronchogenic cancer: It still exists

OBJECTIVES/HYPOTHESIS

Branchial cleft cysts rank among the most common differential diagnoses of cystic cervical masses. Rarely, classic cystic structures exhibit a squamous cell carcinoma differentiation that represents a bronchogenic carcinoma. The existence of bronchogenic carcinoma is controversial due to the lack of systematic immunohistologic workup. The present study aimed to identify the clinical and immunohistologic features of bronchogenic carcinoma to clearly distinguish this entity from other cystic cervical masses.

METHODS

Immunohistologic (epidermal growth factor receptor; cytokeratin 5, 6, 7, 13; and p16) and epidemiologic assessments were performed for branchial cleft cysts (n = 63), bronchogenic carcinomas (n = 5), cystic metastasized oropharyngeal carcinomas (n = 97), and carcinomas of unknown primary (n = 51). The study was conducted as a retrospective case series study with comparison.

RESULTS

The patients with bronchogenic carcinomas differed significantly in age and in the number of involved lymph nodes compared with the cystic metastasized oropharyngeal carcinoma (and carcinoma of unknown primary) patients. Regular histologic wall structures were only observed in the bronchogenic carcinomas and branchial cleft cysts. Solitary cytokeratin-7 staining was only observed in the bronchogenic carcinomas, and all of the bronchogenic carcinomas were p16 negative.

CONCLUSIONS

The existence of bronchogenic carcinoma seems to be plausible based on clinical findings. Cytokeratin-7 and p16 staining might be helpful in the diagnostic workflow.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:638-642, 2016.

Synovial sarcoma of the neck masquerading as a malignant second branchial cleft cyst

Synovial sarcoma is an uncommon, aggressive malignant tumor of the soft tissues primarily involving the extremities of young adults. Head and neck synovial sarcoma is rare, and its diagnosis and therapy are still challenging.We report a case of a young patient with synovial sarcoma, clinically masquerading as cystic mass of the neck and malignant second branchial cleft cyst. The pathological diagnosis of the sarcoma was confirmed by a multimodality diagnostic protocol, including histological, immunohistochemical and molecular genetic analysis. The patient underwent complete surgical excision followed by postoperative radiotherapy and recovered well.

Branchial cleft cyst with xanthogranulomatous inflammation

Xanthogranulomatous inflammation (XGI) is a special type of inflammation presenting as mass lesions and mimicking malignant tumors. It is rarely described in the head and neck region, and to the best of our knowledge, there are no cases associated with branchial cleft cyst. A 39-year-old woman with an infiltrative cystic neck mass that radiologically mimicks a malignant tumor is herein presented. The histopathologic diagnosis was a branchial cleft cyst with XGI. XGI may be associated wih branchial cleft cysts. Patients may present with radiologic findings mimicking an invasive malignant tumor, and should be taken into account during the differential diagnosis with cystic squamous cell carcinoma.