A Rare Case of Right Fourth Branchial Fistula: A Diagnostic Challenge.

Fourth branchial anomalies are extremely rare and are often misdiagnosed. A recurrent history of anterior neck discharges or infections since childhood should raise a high clinical suspicion of branchial fistula and necessitate a thorough clinical, endoscopic, and radiological evaluation. We report a rare case of right-sided fourth branchial fistula in a middle-aged lady who was referred to us for recurrent right neck infections since childhood and had received multiple courses of antibiotics and drainage of abscesses. Despite previous negative barium swallow and fistulogram results, the diagnosis of the branchial fistula was made clinically with the spillage of methylene blue dye into the apex of the right pyriform sinus from flexible nasopharyngolaryngoscopy in the clinic after the injection of dye through the fistula opening at the neck. Finally, another barium swallow study and computed tomography scan were conducted, revealing the fistula tract. Complete surgical excision of the fistula tract was then performed with no evidence of recurrence after six months of follow-up.

Role of methylene blue with fibrin glue in branchial cleft anomaly case report and review of literature.

We report a 3-year-old girl who presented to our clinic with a left-sided neck mass at the junction of the middle and lower thirds of the anterior border of the sternocleidomastoid with a slight tenderness. The patient was then diagnosed with a branchial cleft and was taken for surgical excision. Intraoperatively, we injected methylene blue with fibrin glue using an arterial catheter inside the tract, which facilitated the dissection of the tract.

Cervical thymic cyst ? A Rare Neck Swelling in an Adolescent.

Cystic neck masses in adolescents pose a diagnostic challenge as they be neoplastic or non-neoplastic, congenital, inflammatory, or infectious. Detailed history and examination, anatomical location of the lesion may help narrow down the differential diagnosis of such masses. Cervical thymic cysts contribute to less than 1% cystic lesions in the neck. We present one such case and our management strategy.

Management of first branchial anomalies in children: 20 years of experience.

PURPOSE: Branchial cleft anomalies (BCAs) are common pediatric head and neck lesions; however, only 1-4% involve the first branchial cleft. The rare occurrence of first BCAs, their presentation at a young age, and the possible facial nerve involvement make diagnosis and treatment challenging. METHODS: A retrospective chart review was conducted for children diagnosed with their first BCA between 2000 and 2020. Data on demographics, presenting symptoms, physical findings, imaging features, previous surgery, and treatment outcomes were collected and analyzed. RESULTS: The cohort included 17 patients with a median age of 5 years at presentation. Seven (41%) had undergone previous surgical intervention before definitive surgery. Eight were classified as Work Type II anomalies, and nine as Work Type I. Sixteen patients (94%) underwent definitive surgical excision at a median age of 6.9. A parotid approach was used in 10 (62%), with dissection of the mass from the facial nerve, and a retro-auricular or end-aural approach was used in 6 (38%). Complete excision was achieved in 14/16 patients (88%). Three patients had transient facial nerve paresis postoperatively. Recurrence was noted in 3/16 patients (18%). Enhancement in imaging was positively correlated with post-operative complications (R = 0.463, P = 0.018). CONCLUSIONS: First, BCA poses a diagnostic and surgical challenge; thus, definitive surgical treatment is often delayed. The surgical approach should be tailored to the type of anomaly (Work type I or II) and possible facial nerve involvement. Risk factors for post-operative complications are a history of recurrent infections and previous surgical interventions. The presence of contrast enhancement in preoperative imaging should alert surgeons to perioperative challenges and the risk of post-operative complications.

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.

A rare case of a branchial cyst with calcification: A case report.

Branchial cysts are relatively rare lesions with lymphoid tissue in the underlying epithelium of the cyst wall. The present study describes the case of a branchial cyst with keratinization and calcification that occurred in the right submandibular region, along with a review of the literature. A 49-year-old female patient presented with a complaint of swelling in the right submandibular region. Computed tomography revealed a well-defined, cystic lesion located anterior to the sternocleidomastoid muscle, outside the hyoid bone, and in front of the submandibular gland. The cystic cavity presented an opaque image suggestive of calcification. Magnetic resonance imaging showed high-intensity lesions on both T2-weighted and short-τ inversion recovery images on the anterior margin of the right sternocleidomastoid muscle, just below the platysma muscle, with a clear demarcation from the surrounding tissue, and posterior compression and flattening of the submandibular gland. Cystectomy was performed under general anesthesia, and histopathological examination confirmed the diagnosis of branchial cyst with keratinized and calcified substances. The patient recovered well and had no complications or recurrence at ~2-year follow-up. This case highlights the rare occurrence of a branchial cyst containing calcification in the cystic cavity and provides a literature review of the factors contributing to the calcification.

Web in the Neck - An Interesting Case Report.

Lateral neck masses are common in children, ranging from simple benign diseases to pathologies with malignant potential. Plexiform neurofibromas are extremely rare peripheral nerve sheath tumours involving multiple nerve sheath fascicles. They are typically seen in the paediatric population, with the majority affecting the craniofacial area and neck. Due to the close clinical and histological resemblance with other benign neck lesions such as lymphadenitis and branchial cysts, these cases can often go misdiagnosed. We describe a lesion in a young girl who presented with a progressive lateral neck swelling and how it was managed.

A second branchial cleft cyst, a case report.

INTRODUCTION & IMPORTANCE: Branchial fistulas and cysts are uncommon anomalies of embryonic development that involve soft tissues of the neck. According to Bailey-Proctor classification, second BCCs are classified into four types: Type-I cysts are situated along the anterior border of the sternocleidomastoid muscle beneath the superficial cervical fascia. Type-II ones are the most common and lie just laterally to great vessels beneath enveloping fascia of the neck. Type-III ones pass between internal and external carotid arteries. Type-IV cysts are situated in the pharyngeal mucosal space just deep to the palatine tonsil and medial to great neck vessels, often extending upward towards the skull base. Most second BCCs comprise the first three types, while type-IV cysts are extremely rare. CASE PRESENTATION: 17 years old male patient from Baghdad/Iraq, single, a student, and living with his family. CLINICAL DISCUSSION: The patient presented to Al-kindy Teaching Hospital for general surgery consultation due to the presence of a lump in the upper third of the anterior border of the sternocleidomastoid muscle for several years ago, the lump was painless but gradually increase in size with discomfort but without fever, anorexia or weight loss. There were no relieving factors. Regarding the review of systems nothing positive and the history was negative also patient had no past drug history and no psychological illness. Physical examination of the lump showed a smooth, non-tender, fluctuant cyst located at the upper third of the anterior border of the left sternocleidomastoid muscle about 7 × 4 cm and there were no enlarged lymph nodes. Regarding examination of the other systems there was nothing positive. Laboratory and radiological investigation showed that the cystic lesion mostly was a branchial cyst, so the operation is done for the patient by complete excision of the cyst with its tract which was located between external and internal carotid vessels. A histopathological study revealed a squamous epithelium-lined cyst with lymphoid infiltration, consistent with a branchial cleft cyst. The patient was discharged without any complication or any evidence of recurrence for 14 months follow-up. CONCLUSION: Branchial anomalies remain asymptomatic and can present later in life. They can be misdiagnosed. CT scans and MRI neck are helpful in the diagnosis of the cyst and its anatomical extensions. A proper history and physical examination are required to look for other anomalies like craniofacial syndromes. The treatment of branchial cyst is complete surgical excision to prevent recurrence and removal of these lesions at an earlier stage will increase the quality of life of the patient. In addition, since they are rarely malignant, more successful results will be obtained with early diagnosis and treatment.

Papillary thyroid carcinoma arising from ectopic thyroid tissue in a neck branchial cyst.

A 35-year-old man presented with a right lateral neck mass for 6 years. Thyroid function test was within normal limits. Computed tomography scan of the neck was suggestive of branchial cyst, tuberculous lymphadenopathy and normal thyroid gland. Fine needle aspiration cytology of cervical lymph node was suggestive of metastatic carcinoma. Branchial cystectomy spearing the thyroid gland was undertaken. Histopathology analysis of the resected specimen confirmed it to be papillary thyroid carcinoma originating from ectopic thyroid tissue in a branchial cyst. The patient was scheduled for total thyroidectomy and neck dissection. Unfortunately, he was lost to follow-up. A brief review of the literature regarding this unusual presentation of thyroid cancer has been provided.

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.

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.

Type III Second Branchial Cleft Cyst: A Rare Presentation.

The second branchial cleft cyst (BCC) is the most common type of BCC. Bailey proposed a classification of the second BCC into four types, among which a Bailey type II cyst is the most common presenting lateral to the carotid space. A Bailey type III cyst, which extends between internal and external carotid arteries is an extremely rare occurrence. Complete surgical excision is the treatment modality of choice for branchial cysts and this warrants thorough imaging to see the detailed extent of the cyst. Contrast-enhanced computed tomography and Magnetic resonance imaging, both aid in diagnosis. Here we report a rare case of Type III second BCC, which presented with dysphagia, along with an elaboration of findings on imaging and treatment details.

Microscopic assisted excision of a rare posterior triangle branchial cyst.

Branchial cyst is a painless mass commonly located in the anterior triangle of the neck. It is rarely found in the posterior triangle of the neck. A computed tomography scan of the neck is important to see the extent of the anomaly and its relationship with the major vessel.

Quality and Readability of Online Patient Education Materials Related to Branchial Cleft Cysts.

Introduction Branchial cleft cysts are the second most common congenital neck mass and can cause significant anxiety for patients and families despite their benign nature. Education through online patient education materials (PEMs) is critical for informing patients and reducing stress. We aimed to determine the content, quality, and readability of online PEMs related to branchial cleft cysts. Methods The search engine Google was used to collect the first 100 website results for the query "branchial cleft cyst." PEMs were included and assessed for content, quality via the DISCERN tool, and readability via Flesch Reading Ease Score (FRES), Flesch-Kincaid Reading Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG). Results Twenty-six websites containing PEMs related to branchial cleft cysts were assessed. Most websites were from universities or medical centers and did not contain any media. The mean DISCERN score was 49.3 (SD: 11.1, Median: 52.5), the mean FRES score was 51.9 (SD: 12.1, Median: 54.0), the mean FKGL score was 10.35 (SD: 2.52, Median: 9.95), the mean GFOG score was 13.32 (SD: 2.52, Median: 13.00), and the mean SMOG score was 10.25 (SD: 1.83, Median: 9.95). DISCERN was not significantly correlated with FRES, FKGL, GFOG, or SMOG. Conclusion Online PEMs related to branchial cleft cysts are consistently written above the National Institutes of Health (NIH) recommended sixth-grade reading level and are often of unsatisfactory overall quality. Writers of online PEMs for branchial cleft cysts should consider the readability and quality of their materials to improve patient education and reduce anxiety.

Management of Nasopharyngeal Cyst of Second Branchial Cleft Origin: Case Series and Systematic Review.

Branchial cyst of the second pouch is the most common lesion of the nasopharyngeal lateral wall, generally localized between the pharyngeal wall and internal carotid artery. Cases consistent with such lesion, were collected. Symptomatic patients were treated with endoscopic trans-nasal marsupialisation, asymptomatic cases were followed-up. Among the 10 patients included, 4 were symptomatic and accordingly treated. In the literature, 36 cases were found, all of which were treated, most commonly with a total excision. Considering the benign nature of branchial nasopharyngeal cyst, its treatment should be tailored to each patient: endoscopic marsupialization in symptomatic lesion, follow-up in asymptomatic one. Laryngoscope, 132:1904-1908, 2022.

A Systematic Literature Review to Compare Clinical Outcomes of Different Surgical Techniques for Second Branchial Cyst Removal.

OBJECTIVE: During the last 2 decades, new treatment methods have been developed for the surgical removal of second branchial cysts which result in less visible scars. The aim of this systematic review is to assess which surgical technique for second branchial arch cyst removal results in the lowest complication and recurrence rates with the highest scar satisfaction. METHODS: Two authors systematically reviewed the literature in the Cochrane, PubMed, and EMBASE databases (search date: 1975 to December 2nd, 2020) to identify studies comparing surgical outcomes of second branchial arch cyst removal. Authors appraised selected studies on directness of evidence and risk of bias. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: Out of the 2442 retrieved articles, 4 articles were included in the current review including a total of 140 operated cysts. Only 2 studies included pre-operatively infected cysts. Follow up ranged from 3 to 24 months. Complication rates ranged from 0 to 27.3% (conventional: [0-10.4%]; endoscopic/retro-auricular: [0-27.3%]). None of the patients presented with postoperative recurrence. Significantly higher scar satisfaction was found in adult patients who underwent endoscopic or retro-auricular hairline incision cyst removal. CONCLUSION: No recurrence of disease occurred during (at least) 3 months of follow up using either conventional surgery or endoscopic/retro-auricular techniques. Although more (temporary) complications occur using endoscopic and retro-auricular techniques, patients report a significantly higher scar satisfaction 3 to 6 months after surgery in comparison to the conventional technique. Future studies are needed to support these findings.

[Cancerization of first branchial cleft cyst in the parotid gland: one case report].

A rare case of branchiogenic carcinoma from first cleft branchial cyst in the parotid gland is reported. An elderly male patient was admitted to the hospital presented with a mass accompanying with swelling and pain in the right parotid area for 5 days. Total right parotidectomy including the tumor resection and selective neck dissection were performed under general anesthesia. A thick-walled cyst containing necrotic tissue in the parotid gland was found. Postoperative histopathology showed that the tumor contained squamous epithelium and pseudostratified columnar epithelium. The cyst epithelium had atypical hyperplasia with necrosis. Some areas were cancerous with the formation of well-differentiated squamous cell carcinoma and cancer infiltration. No metastasis was found in the cervical lymph nodes. This case was in accordance with the diagnostic criteria of cancerization of the first branchial cleft cyst.

Thrombosed external jugular vein aneurysm mimics to a branchial cyst: A novel case from Iraq and review of the literature.

INTRODUCTION AND IMPORTANCE: Venous aneurysms are rare diseases, and according to their locations, history will change. They will be diagnosed based on the clinical history and imaging modalities. The exact incidence of external jugular vein aneurysm remains controversial. In the neck, venous aneurysm has been reported most commonly in the internal jugular vein. Frequently the venous aneurysm has a fusiform shape, and the saccular type is extremely rare. CASE PRESENTATION: Here we present a case of the external jugular vein aneurysm which was misdiagnosed as a branchial cyst presented with gradual swelling in the left supraclavicular region. The patient was diagnosed intraoperatively, and by histopathological examination. The patient successfully underwent surgery of Proximal and distal control of the external jugular vein without resection of the clavicle were performed, and trans-fixation of the external jugular vein was done without any complications. CLINICAL DISCUSSION: Idiopathic, spontaneous venous aneurysm of the external jugular vein thrombosis is extremely rare clinical findings. Computerized tomography was the gold standard test for the diagnosis of venous thrombosis, but nowadays neck ultrasound is the diagnostic test of choice. However, the mass was like a branchial cyst by ultrasound. CONCLUSION: External jugular vein aneurysm is rare, when it was a saccular type and thrombosed without any causes it will be extremely rare. When idiopathic thrombosis of external jugular vein aneurysm was confirmed by imaging modalities, then it was symptomatic, enlarged, ruptured or disfigured, the surgical excision will be mandatory without anticoagulant drugs preoperatively or postoperatively.

Mediastinal basaloid carcinoma arising from thymic cysts in two dogs.

Mediastinal masses in dogs were diagnosed as basaloid carcinoma associated with multiple thymic cysts (MTCs). The masses were composed of MTCs and proliferating intracystic neoplastic basaloid cells, which immunohistochemically diffusely expressed p63 and cytokeratin 19. A gradual transition from the basal cell layers lining the cysts walls to the neoplastic cells was seen, and it was indicated that the neoplastic cells had originated from the basal cell layers of the cysts. To the best of our knowledge, this is the first report of basaloid carcinoma occurring in the mediastinal cavity in dogs. Although these tumors were demonstrated to be rare origins, basaloid carcinoma should be included in the differential diagnoses for canine mediastinal tumors.

Primary branchiogenic carcinoma: malignant degeneration of a branchial cyst, a case report.

BACKGROUND: Primary branchiogenic carcinoma (PBC) is an extremely rare and poorly documented disease developed from a brachial cleft cyst. CASE: A 51-year-old patient was referred to our unit for an upper neck mass. PBC was confirmed in accordance with Kahfif's diagnostic criteria. Prophylactic selective neck dissection was performed in a second-stage surgery to ensure the complete removal of the neoplasm. Branchiogenic origin with lymphoid tissue was confirmed in the "host cyst" after histological examination and no other tumors were found elsewhere. Regular follow up documented no relapse 12 months after surgery. CONCLUSIONS: Although rare, PBC must be suspected in presence of cervical masses, especially in patients older than 40 years. A standardized treatment algorithm still lacks, but prophylactic selective neck dissection could be considered as the first line choice after the diagnosis has been confirmed.