branchialcleftcyst ger

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Branchial Cleft Cyst



What is a Branchial Cyst?

Definition:

Congenital epithelial cysts, which ariseon the lateral part of the neck due to

failure of obliteration of the second

branchial cleft in embryonic development.



Branchila cleft cyst = Lymphoepithelial

cyst “Lymphatic origin, Modern Theory”

The name branchial means in Greek “Gill”

, Those structures are responsible of

development of Gills in fish. “Classic

Theory”

Commonest cysts to arise in the neck.



Classical location

Anterior to the

sternocleidomastoid

muscle.

However there havebeen a number of

case reports

describing cysts

which were found inareas other than the

classical position.



Etiology

Many theories

They can be grouped into two categories:

the congenital The cervical lymph nodes cystic

transformation theories.



Easier approach to Embryology

Structures between the developing head

and the heart (i.e., the face, neck,

oropharynx, and the larynx) develop from

the branchial apparatus.

There are six branchial arches; the last

two are rudimentary.

Each arch has a bar of mesoderm.



Caudal to each of the four arches is an internal

pouch lined with entoderm.

Externally is branchial cleft, lined with ectoderm.

Between each bar, a branchial plate, composed

of entoderm and ectoderm, separates thebranchial cleft from the branchial pouch.



Anatomical Considerations

The second arch growsdownwards and ultimatelycovers the third andfourth arches.

The buried clefts normallydisappear around theseventh week of development.

If a portion of the cleft

remains entrapped andfails to disappear, itsremnants form a cyst.



Second cleft Cyst with tract

extending up to Pharynx

Note tract goes

between internal &

external carotid

arteries and close tocranial nerves IX, X,

XII which control

among other functions

tongue movement andswallowing.



Clinical Presentation



History

Solitary, painless mass in the neck of a child

or a young adult.

History of intermittent swelling and

tenderness of the lesion during upper respiratory tract infection may exist.

Discharge if associated with a sinus tract.

May present with locally compressivesymptoms.

+ family history.



Physical Examination

Primary lesion: Branchial cysts are smooth,

nontender, fluctuant masses, which occur

along the lower one third of the anteromedial

border of the sternocleidomastoid musclebetween the muscle and the overlying skin.

Secondary lesion: The lesion may be tender

if secondarily inflamed or infected. When

associated with a sinus tract, mucoid or purulent discharge onto the skin or into the

pharynx may be present.



Diagnosis

Cyst arising off midline of the neck and havinglymphoepithelial characteristics should beregarded as a branchial cyst.

Usually occur in the 2nd or 3rd decade of life.

Most commonly found in the anterior triangle of the neck anterior to the upper third of thesternomastoid.

A cyst occupying the posterior triangle is

extremely rare. Hence they should be suspected in all the cystic

swellings of the neck except the median ones.



Imaging

On general principle it’s less helpful than

expected

Although you can always tell where is the

lesion, but differentiating between other

causes of cystic neck masses is not

always easy.



Ultrasound

Well defined, echogenic mass usuallyanterior to the carotid artery, draped

anterior to the sternocleidomastoid muscle



CT

Well defined, low density unilocular mass

with a thin uniformly enhancing rim



Axial contrast-enhanced CT scan shows a left-sided cyst with a thick, enhancing

rim. This cyst is behind the submandibular gland, lateral to the carotid sheath

structures, and deep to the anterior margin of the sternocleidomastoid muscle.

There is an enhancing tract (arrow) extending from the cyst toward the left palatine

tonsil. This was an infected second branchial cleft cyst with an internal tract. Such

a tract typically passes between the internal and external carotid arteries and ends

in the palatine tonsil.



MRI

MRI allows for finer resolution during

preoperative planning. The wall may be

enhancing on gadolinium scans.



Differential Diagnosis

Branchiogenic carcinoma Tuberculous adenitis

Lipoma

Metastatic malignant neoplasms (SCCA from a primary site in theaerodigestive tract)

Cystic hygroma (lymphangioma) Carotid body tumors

Lymphomas

Hemangiomas

Thyroid cysts

Ectopic thyroid Cervical thymic cysts

Thyroglossal duct cyst

Parotid cystic tumors



Axial contrast-enhanced CT scan

shows a well-delineated fatty

mass in the subcutaneous tissues

of the back of the neck.

Branchial cleft cyst




Cystic hygroma

Cystic lymphangioma



Parotid, malignant tumors. Axial T1-

weighted MRI with fat saturation and

contrast enhancement shows an

enhancing mass extending into the

superficial and deep lobes of the right

parotid gland. Pathology indicated a

squamous cell carcinoma.




T1-Weighted MRI. A well

defined mass is present along the

anterior triangle of the neck on

the right side. There are low

signal regions

within this mass suggesting the

presence of calcifications andflow-voids (arrows).

T2-Weighted Axial Images

Through the Submandi-

bular Region. The mass is bright

on T2-weighted images and

again exhibits focal lucencies

compatible with flow voids.

Contrast Enhanced MR in the

Axial Plane.

There is bright enhancement of

the mass. Flow voids

produce a "salt and pepper"

appearance.

Paragangl iomas

http://images.google.de/imgres?imgurl=http://img.medscape.com/fullsize/migrated/510/370/ar510370.fig18.jpg&imgrefurl=http://www.medscape.com/viewarticle/510370_4&usg=__jCY39rA2VpoIMFumlXyjvV95X6U=&h=508&w=400&sz=28&hl=de&start=15&um=1&tbnid=RIeolhST_lEH0M:&tbnh=131&tbnw=103&prev=/images%3Fq%3DHemangiomas%2Bof%2Bthe%2Bneck%26ndsp%3D18%26hl%3Dde%26lr%3Dlang_hy%257Clang_en%26rlz%3D1R2SNYK_de%26sa%3DG%26um%3D1



Axial contrast-enhanced CT scan

shows a well-delineated irregular mass

lesion taking early KM enhancment

Hemangioma


http://images.google.de/imgres?imgurl=http://img.medscape.com/fullsize/migrated/510/370/ar510370.fig18.jpg&imgrefurl=http://www.medscape.com/viewarticle/510370_4&usg=__jCY39rA2VpoIMFumlXyjvV95X6U=&h=508&w=400&sz=28&hl=de&start=15&um=1&tbnid=RIeolhST_lEH0M:&tbnh=131&tbnw=103&prev=/images%3Fq%3DHemangiomas%2Bof%2Bthe%2Bneck%26ndsp%3D18%26hl%3Dde%26lr%3Dlang_hy%257Clang_en%26rlz%3D1R2SNYK_de%26sa%3DG%26um%3D1



Treatment

The treatment of branchial cleft cysts is

surgical excision.



This branchial cleft cyst was followed superiorly to theregion of the oropharynx, but no communication was

found. The picture below shows the anatomy of the carotid

triangle after removal of the cyst.



Marina Waves, Salmiya Waterfront, Kuwai

branchialcleftcyst ger

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