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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 have been a number of case reports describing cysts which were found in areas other than the classical position.
Etiology
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 the
Anatomical Considerations
The second arch grows downwards and ultimately covers the third and fourth arches. The buried clefts normally disappear around the seventh week of development. If a portion of the cleft remains entrapped and fails to disappear, its remnants form a cyst.
Note tract goes between internal & external carotid arteries and close to cranial nerves IX, X, XII which control among other functions tongue movement and swallowing.
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 compressive symptoms. + 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 muscle between 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 having lymphoepithelial characteristics should be regarded 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 the sternomastoid. 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 its 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 usually anterior to the carotid artery, draped anterior to the sternocleidomastoid muscle
CT
Well defined, low density unilocular mass with a thin uniformly enhancing rim
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 the aerodigestive 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 Parotid, malignant tumors. Axial T1weighted 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
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 and flow-voids (arrows).
T2-Weighted Axial Images Through the Submandibular 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.
Paragangliomas
Axial contrast-enhanced CT scan shows a well-delineated irregular mass lesion taking early KM enhancment
Hemangioma
Treatment
This branchial cleft cyst was followed superiorly to the region of the oropharynx, but no communication was found. The picture below shows the anatomy of the carotid triangle after removal of the cyst.