Pediatric: Branchial Cleft Cyst

What are: Branchial Cleft Cysts?

Branchial Cleft Cysts are epithelial (skin) lined cavities filled with mucous that form a mass along the side of the neck. These are congenital (abnormality during fetal development) cysts, resulting from a failure of gill-like embryonic structures (branchial arches) to disappear during maturation of the fetus, as they normally should. This results in a persistent pouch, which later can fill with fluid. Although the cyst is present at birth, it may not present until years later.

Symptoms and Types:

Branchial cleft cysts typically appear between childhood and young adulthood as a slow-growing, painless mass on the side of the neck. Infection of the cyst causing an abscess may be the presenting complaint. Depending on the size, it may cause trouble swallowing and shortness of breath. Two percent may be bilateral.

The four types of branchial cleft cysts are named after the branchial arches that they arise from -- first, second, third, and fourth. The first branchial cleft cyst has two types: type I and type II. Type I first branchial cleft cysts are rare, and represent a duplication of the external ear canal. These can be near the facial nerve, which is responsible for movement of the face. A type II first branchial cleft cyst is more common and can present as a mass just below the angle of the jaw. The cyst can have a persistent tubular structure through the parotid gland (the large salivary gland located on the face) with close association to the facial nerve. The tubular structure may end at or in the external ear canal. Second branchial cleft cysts are the most common and may present as a painless mass under the jaw line but in front of or under the large neck muscle know as the sternocleidomastoid muscle. Third and fourth anomalies are rare. The third may present as a mass in the lower lateral neck while the fourth may drain into the throat.

Branchial cleft cysts create problems as they enlarge or become infected. Abscess formation often leads to emergency incision and drainage to control infection. Consequently, this can lead to additional scarring, making eventual definitive surgery more challenging. Dissection of the deep tubular remnants of these cysts from around the facial nerve and other nerve and vascular structures of the neck is important to prevent their recurrence.

Treatment and Care:

Elective surgical removal is the treatment of choice. If there is an abscess, emergency incision and drainage is necessary. The goal, however, is to remove the cyst prior to infectious complications. Your doctor may order a CT scan or an MRI to aid in diagnosis and surgical planning.

 

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