Ultrasound diagnosis and treatment of branchial cleft cyst and preoperative management.

OBJECTIVE: The ultrasonic diagnosis of cervical and facial cystic masses, as well as cases of missed diagnosis and misdiagnosis, was examined, to improve the diagnosis of branchial cleft anomalies. METHODS: A retrospective analysis was conducted on 17 patients with branchial cleft cyst anomalies, including 11 males and 6 females, aged 12-53 years, with an average age of 33 ± 2 years, were unilateral single. All patients who underwent an ultrasound examination and image storage for retrospective analysis, and both longitudinal and transverse sections were scanned to observe the shape, size, boundary, peripheral relationship, and blood flow signal of the masses. All cases were examined with an enhanced CT scan, and pathological reports were generated. RESULTS: Among the 17 cases of branchial cleft anomalies, 15 cases were branchial cleft cysts, while one case involved fistula formation and one case involved sinus tract formation. Based on the type of branchial cleft, the first, second, and third cysts were classified in 4, 12, and 1 case, respectively. The sensitivity rate and specificity of ultrasonic diagnosis were 14/17 (82.4%) and 4/6 (66.7%), respectively. Ultrasonic characteristic analysis for the masses can be found in simple cystic masses or hypoechoic masses, most of them are of a regular shape and have a distinct boundary, and almost no blood flow signal. All patients who were misdiagnosed exhibited blood flow signals, including 1 patient with an abundant blood flow signal, 1 patient suspected of having ectopic thyroid with an abnormal function due to the rat-tail sign, 2 patients misdiagnosed as local inflammatory focus, and 1 patient misdiagnosed with tuberculous lymphadenitis. CONCLUSION: Ultrasound has a detection rate of up to 100% for cervical and facial masses, providing a fundamental determination of lesion characteristics and specific guidance for preoperative diagnosis. If the blood flow signals can be identified and carefully considered their peripheral relationship, the diagnostic rate can be improved.

Scarless Excision of Second Branchial Cleft Cyst via Retroauricular Hairline Incision.

BACKGROUND: Second branchial cleft cyst (2nd BCC) is treated by complete excision. Conventional transcervical skin incision on the lesion may leave a prominent scar in the cosmetically sensitive area. The retroauricular hairline incision (RAHI) approach may maintain neurological, mobility, and cosmetic functions of the neck and face after excision. This study evaluated the clinical outcomes and disease control of scarless surgery via RAHI in 57 consecutive patients with 2nd BCC. METHODS: The patients received the prospective evaluation of postoperative neurological, subjective pain, swallowing, neck motion, and cosmetic functions. Postoperative complications, subjective satisfaction, and recurrence were also assessed in each patient. RESULTS: Excision was performed in all cases without injury to the facial nerve or other neurological complications and conversion to other incisions or approaches with a median operation time of 44 min. Complications were minimal, without dysphagia, neurological deficits, or limited neck motion. Postoperative incision scars in the postauricular and hairline region were commonly invisible. Subjective satisfaction with the scar and facial deformity was high after surgery. No patients had a recurrence for a median follow-up of 66 months. CONCLUSION: The RAHI approach for 2nd BCC has excellent cosmetic, functional, and disease control outcomes. This can be safely applied to the treatment of 2nd BCC. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Branchiogenic cyst ‒ a rare finding in vascular surgery.

Branchiogenic cysts are benign lesions caused by anomalous development of the branchial cleft. They are typically detected in individuals aged between their twenties and forties. Ultrasonography is the first-line imaging method of choice. Surgical excision is the sole treatment modality (Tab. 1, Fig. 6, Ref. 25). Keywords: branchiogenic cyst, extirpation, ultrasonography, computed tomography.

Patho-Anatomic Spectrum of Branchial Cleft Anomalies: Proposal of Novel Classification System.

PURPOSE: Histogenesis, nomenclature, and classification of branchial cleft anomalies (BCAs) have been subjects of controversy for decades. The purpose of this study was to investigate the accuracy of current developmental theories (congenital, lymph node, and hybrid branchial inclusion theories) in defining the anatomic and histopathological characteristics of BCAs. METHODS: Ninety consecutive patients with BCAs who underwent surgical excision were enrolled in this 2-center retrospective cohort study. RESULTS: The present study included 90 patients: 46 (51.11%) women and 44 (48.89%) men (P > .05). The mean age at presentation was 31.89±17.31 years. Altogether, 92 BCAs were identified within the study population including 49 (53.26%) on the left side and 43 (46.74%) on the right side (P > .05). The BCAs included 79 (85.87%) branchial cleft cysts, 11 (11.96%) branchial cleft sinuses, and 2 (2.17%) branchial cleft fistulae. Three (3.26%) BCAs were distributed in the head regions, 88 (95.65%) in the neck regions, and 1 (1.09%) in the thoracic cavity. Following surgery, lymphoepithelial tissue was detected in the histopathological examination in 83 (90.22%) BCAs. The hybrid branchial inclusion theory exhibited significantly higher accuracy in defining patho-anatomic characteristics of BCAs than the branchial apparatus, precervical sinus, thymopharyngeal, and inclusion theories (90.22, 9.78, 2.17, 0.00, and 0.00%; respectively) (P < .05). CONCLUSION: The novel branchial node (BN) classification system based on the hybrid branchial inclusion theory appears to be superior to other classification systems in determining the patho-anatomy of BCAs.

Postauricular Incision Versus Conventional Transcervical Incision in Second Branchial Cleft Cyst Excision: A Systematic Review and Meta-Analysis.

Surgical removal is the treatment of choice for second branchial cleft cysts (SBCCs), which are congenital anomalies. The conventional procedure is performed through a transcervical approach, which would lead to a visible scar in the anterior neck. Conversely, the postauricular approach could keep the scar in the hairline or retroauricular sulcus, rendering it almost invisible after the surgery. The purpose of this meta-analysis was to evaluate the differences between the postauricular and conventional transcervical approaches to SBCC excision. A systematic review was performed using PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes of SBCC surgery via postauricular and conventional transcervical approaches. The data of interest were analyzed with Comprehensive Meta-Analysis software (version 3). The data of interest were analyzed by calculating the risk difference (RD), the standardized mean difference, and the mean difference (MD) with the 95% confidence interval (CI). Three studies were eligible for the final analysis. The pooled analysis demonstrated that the cosmetic satisfaction score was significantly higher with the postauricular approach (standardized mean difference, 2.12; 95% CI, 0.68-3.56). The operative duration was significantly longer with the postauricular approach than with the conventional transcervical approach (MD, 12.81; 95% CI, 2.39-23.23). The incidences of postoperative marginal mandibular nerve palsy (RD, 0.00; 95% CI, -0.09 to 0.09), bleeding complications (RD, -0.02; 95% CI, -0.09 to 0.05), salivary complications (RD, -0.00; 95% CI, -0.07 to 0.06), cyst size (MD, 0.02; 95% CI, -0.96-0.99), and length of hospital stay (MD, -2.50; CI, -7.30 to 2.30) were comparable between the 2 groups. The postauricular approach is feasible for use in SBCC excision and yields better cosmetic outcomes, a longer operative duration, and a similar rate of complications.

Horn-shaped Symmetric Nodules on the Earlobes: An Unusual Presentation of First Branchial Cleft Anomaly.

First branchial cleft anomaly (BCA) is a rare congenital malformation of the head and neck, <10% of all BCA. it occurs between the first and second branchial arches. The diagnosis of first BCA is often delayed because of its atypical shape and rarity. A 30-year-old male presented to our clinic with bilateral earlobes nodules, he first noticed ~20 years prior. The lesions had gradually increased in size, and he stated no other specific symptoms. Bilaterally, a 1-cm-sized, sharp, horn-shaped, dark-colored, keratinized mass was palpated hardly, and no infectious signs were observed. Bilateral resection was performed, and the lesions did not form a tract in any other direction. Histopathology confirmed the lesions were first BCA composed of a cystic cavity lined by stratified squamous epithelium. Surgeons should suspect first BCA in patients with nonspecific lesions of the earlobe, and our case will help with future diagnoses.

Branchial cleft anomalies: hybrid "Branchial Inclusion" theory.

PURPOSE: Branchial cleft anomalies (BCAs) are developmental malformations of the head and neck region. Their histogenesis has been the subject of controversy and is not fully understood. This study aimed to test all present developmental theories ("branchial apparatus," "precervical sinus," "thymopharyngeal," and "inclusion" theories) on a sample of 48 BCAs from a single institution. METHODS: We performed a retrospective analysis of clinical-epidemiological and anatomical-pathological characteristics of BCAs treated over a 12-year period in our hospital. RESULTS: Overall, 46 patients (24 [52.17%] women and 22 men [47.83%]) underwent surgical excision of 48 BCAs. The mean patient age at presentation was 31.65 ± 19.40 years. Branchial cleft cysts were found in 42 (87.50%) cases, and branchial cleft sinuses were found in six (12.50%) cases. Eight (16.67%) BCAs were distributed in the preauricular region, 34 (70.83%) at the anterior border of the sternocleidomastoid muscle (SCM), three (6.25%) at the posterior border of the SCM, two (4.17%) in the suprasternal notch, and one (2.08%) in the retrosternal space. Histopathologically, 39 (81.25%) BCAs had a lymphoepithelial structure and nine (18.75%) BCAs had solitary epithelial cells. Inflammation and infection were observed in 24 (50%) and 12 (25%) cases, respectively. CONCLUSION: None of the hypothesized developmental theories fully explain the embryonic origin of BCA in our study sample. A possible explanation of BCA histogenesis is through the hybrid "branchial inclusion" theory.

Unusual Presentation of a Large Multilocular Second Branchial Cleft Cyst.

Second branchial cleft cysts (BCCs) are the most common type of branchial abnormalities and usually found high in the neck. Oropharyngeal presence of a BCC is very rare. The authors report a rare case of oropharyngeal, second branchial, multilocular, cleft cyst in a 9-year-old child (8.0 × 5.0 cm in maximum diameter). The cyst was removed completely via extra/intraoral approach and did not have tract-like structure. The anatomic location together with the histopathology results, which showed a squamous epithelium-lined cystic wall with lymphoid aggregation, were characteristic findings of a BCC. Patient was discharged without any complication, and a regular follow-up of 6 months showed no evidence of recurrency. Having reviewed the literature, it seems to be that this is the first case to be reported of a multilocular BCC, excised of this size, from the oropharyngeal area in a child. Other pathological lumps of the neck have similar presentation with BCC, which makes it difficult, sometimes, to reach an accurate diagnosis. Clinicians should be aware of this pathology because it can be easily misdiagnosed as an odontogenic cyst and/or salivary gland infection, especially if it develops high up in the neck.

Cervical Thymic Cyst Around Hypoglossal Nerve.

Cervical thymic cyst is rare lesions leading to cervical mass. As it is a rare entity, it might be confused with other congenital neck masses or neoplastic lesions. Preoperative diagnosis is almost impossible. In the present study, a patient who was operated with prediagnosis of branchial cyst and diagnosed with thymic cyst according to the histopathologic examination was presented. A 16-month-old girl was admitted to our clinic with the complaint of growing right neck mass that was realized about 4 months ago. Magnetic resonance imaging (MRI) of the neck demonstrated a rim-enhanced hypointense cystic lesion in the posterior aspect of the submandibular gland, without tracheal right lateral and mid plane on MRI, curving common carotid artery to the medial. Patients underwent surgery under general anesthesia in company with existing findings. Hypoglossal nerve was surrounded by the mass, and the mass was totally resected. The final pathology result was reported as thymic cyst. Cervical thymic masses might be unnoticed in the differential diagnosis of the cervical mass as they are rarely seen entities. Histopathologic examination of the thymus tissue was performed for diagnosis. Surgical excision is the ideal treatment approach and no postoperative recurrence has been reported.

Surgical Management of an Intrathoracic Branchial Cyst in a Yellow-crested Cockatoo (Cacatua sulphurea).

A 40-year-old, female lesser crested cockatoo (Cacatua sulphurea) was presented with a complaint of hyporexia and sudden onset of sneezing and wheezing. Physical examination revealed mild stertorous inhalation, and the apex of the heart was palpable caudoventral to the distal tip of the sternum. Projection radiographic images showed a soft tissue mass displacing the heart and the thoracic portion of the trachea. A subsequent computed tomography series revealed a single, large, and predominantly encapsulated soft-tissue mass. The mass was contained within the cranial thoracic region and occupied most of the anatomic location of the thoracic portion of the clavicular air sac, extending around a portion of the trachea. A surgical exploratory procedure was performed, with a thoracic inlet thoracotomy, and the mass was found to be cystic and deeply attached to surrounding tissues at its caudal-most aspect. Complete excision was not possible, and the mass was drained and an incomplete resection was accomplished with approximately one-half of the cystic structure removed and submitted for histopathology. The mass was found to be benign, epithelial-lined, dense, fibrous connective tissue that would be consistent with a branchial cyst.

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.

Drain Usage in Head and Neck Surgery: A National Survey of Thirty-five Surgeons across Ten Units

Introduction Drain usage is commonplace in head and neck surgery. There is an increasing body of literature disputing their routine placement in certain procedures. The aim of this study is to explore modern-day practice in terms of drain usage and the use of haemostatic agents. Methods A simple questionnaire was devised and sent to 35 ENT Surgeons across 10 units nationally. Results There was an overall response rate of 77.1% (n=27). There was considerable heterogeneity amongst surgeons in terms of indication for insertion, how the decision is made to remove the drain and if any alternative/adjunctive haemostatic agents are being used. Discussion The management of drains is poorly defined and guidelines are lacking. With increased pressure on resources, the risk of infection and discomfort to the patient, further reflection is required to evaluate if careful patient selection rather than habitual drain insertion in every case is more appropriate.

Primary Branchiogenic Carcinoma.

BACKGROUND: Primary branchiogenic carcinoma (BC) is an exceptional diagnostic entity. In most cases, suspicion of BC is confirmed to be a cystic lymph node metastasis of an occult primary tumor. Martin and Khafif therefore established diagnostic criteria, emphasizing above all the importance of a histologically assessed transformation of cystic lining epithelium into an invasive squamous cell carcinoma in one pathological lesion after the exclusion of a primary tumor. CASE REPORT: We present a case report of an 80-year-old patient who presented for a follow-up for an 8-year history of a benign lateral cervical cyst, which was not surgically treated due to the patients high risk of complications from general anesthesia. In spite of the risk, the surgery was performed after a sudden clinical progression, and surprisingly, post-operative histology revealed BC. Conslusion: BC is a very rare entity, strictly defined by Martins and Khafifs criteria. Recently, BCs have been presented in the literature only as unique case reports responding as in our patient to the above mentioned criteria, with particular emphasis on the histological aspect, imaging the cystic lining epithelium transforming into an invasive squamous cell carcinoma in one pathological lesion and a long history without evidence of primary tumor. Key words: branchiogenic carcinoma - lateral branchial neck cyst - occult carcinoma - metastasis of unknown primary origin.

Comparison of the Retroauricular Approach and Transcervical Approach for Excision of a Second Brachial Cleft Cyst.

PURPOSE: Although a retroauricular (RA) approach has been proposed for excision of a second brachial cleft cyst (BCC), no studies have performed a direct comparison of the results of the RA approach and those of the conventional transcervical approach. We evaluated the surgical outcomes of the RA approach under direct vision and demonstrate its benefits compared with the conventional transcervical approach for excision of a second BCC. PATIENTS AND METHODS: From January 2012 to May 2016, we enrolled 30 consecutive patients with a second BCC who underwent surgical excision as a primary treatment into the present prospective case-control study. Of the 30 patients, 13 underwent excision of a second BCC with the RA approach and 17 with the conventional transcervical approach. The surgical results, complications, and subjective scar satisfaction scores were estimated and compared between the 2 groups. RESULTS: In all 30 patients, excision of the second BCC was successfully completed under direct vision using the RA or conventional transcervical approach. The mean operating time was significantly less in the conventional group than that in the RA group (68.4 vs 83.4 minutes, respectively; P = .019). No differences were found in the total drainage amount, drainage duration, duration of hospital stay, or postoperative complications between the 2 groups. The mean scar satisfaction score was 6.2 in the conventional group and 8.8 in the RA group, and this difference was statistically significant (P < .001). CONCLUSIONS: The RA approach under direct vision for excision of a second BCC is feasible and results in better cosmetic outcomes than the conventional transcervical approach, with no increase in surgical morbidity.

A branchial cyst of the pyriform fossa transoral laser resection: a case report.

Pyriform sinus malformations represent rare third and fourth branchial anomalies. Fistulae at the latter site were initially described and make up less than 1 % of all brachial anomalies. They may be discovered incidentally, or may present as a neck mass with recurrent infection, dysphagia, or airway compromise, and can be an unusual cause of dysphonia in infant and children. Here, we present a case of third branchial cyst located in pharyngeal wall of the left pyriform sinus which presented with dysphonia since birth in a 6-year-old girl. Transoral CO2 laser excision was carried out successfully with no communicating tract. The patient's dysphonia showed progressive regression at 1-year follow-up. Third branchial cyst in the left pyriform sinus (Bailey's type IV) is an unusual cause of dysphonia in pediatric. Our present case report is the first brachial cyst to be reported in the pyriform fossa and the second branchial anomalies to be excised transorally with CO2 laser.

Assessment and management of presumed branchial cleft cysts: our experience.

Assessment and management of presumed branchial cleft cysts: our experience. OBJECTIVES: The aim was to assess the accuracy of diagnosis and management of presumed branchial cleft cysts in our centre. METHODOLOGY: Retrospective review of patients with a clinical diagnosis of branchial cleft cyst at B arts Health NHS Trust from 2009 to 2015. RESULTS: 67 patients underwent surgical excision for presumed branchial cysts. Ninety per cent were histologically confirmed, 7% demonstrated cystic metastatic squamous cell carcinoma, and 3% lymph node metastases from papillary thyroid cancer. No patient had pre-operative Multi-Disciplinary Team (MDT) discussion. Pre-operative FNA had a positive predictive value of 90% (95% Cl 0.82-0.95). Age >40 years (p=0.02) and presence of lymph nodes (p=0.02) carried a higher risk of malignancy. CONCLUSIONS: Patients >40 years with or without multiple lymph nod 'es on imaging should be treated as presumed meta- static cancer. Consideration should be given to concurrent panendoscopy and intra-operative frozen section +/- selective neck dissection after discussion at the Head & Neck MDT.

[Congenital cysts and fistulae in children]. / Kystes et fistules congénitaux de l'enfant.

Cysts and fistulae of the face and neck in children are formed before birth and correspond to the persistence of embryonic remnants that occur due to coalescence defects of embryonic buds or due to epidermal inclusion. They represent the most common pathological malformation of the face and neck. They may be separated according to their location into laterocervical cysts and fistulas or median cysts and fistulas. Their discovery may occur prematurely at birth or later during growth or in adulthood. Their treatment always requires surgical excision, which must be complete in order to prevent recurrences.