A branchial cleft cyst arises from the incomplete obliteration of one of the four branchial clefts during embryogenesis. As obliteration of the clefts occurs, a portion may remain, forming a cystic space with an epithelial lining and no connection to the skin or pharynx. The anatomic location of a branchial cleft cyst depends on the specific arch/cleft involved. Involvement of the 1st cleft may result in a cyst in the region of the parotid gland, the preauricular or postauricular area, or inferior to the angle of the mandible. Second cleft anomalies represent 70% to 90% of cysts and may be found along the anterior border of or deep to the sternocleidomastoid muscle, in the vicinity of the carotid arteries. Third and 4th arch/cleft anomalies are rare. A cyst usually presents clinically as a lateral, tender neck mass due to acute infection and enlargement usually in association with an upper respiratory infection.
Management and Disposition
Diagnosis is suggested by history and location of physical examination findings. A CT scan or magnetic resonance imaging may help to define the extent of the lesion. Definitive diagnosis comes from pathologic examination after surgical excision. Treatment includes antibiotics if there is an associated infection followed by complete surgical excision by a specialist in order to prevent recurrence and because these lesions may be intimately involved with major vessels and nerves.
Branchial cleft anomalies are second only to thyroglossal duct cysts in frequency of congenital head and neck lesions in children.
First Branchial Cleft Cyst. Periauricular mass from a first brachial cleft cyst. (Photo contributor: Lawrence B. Stack, MD.)
Second Branchial Cleft Cyst. Right neck mass seen in second branchial cleft cyst. (Photo contributor: Scott Manning, MD.)
Second Branchial Cleft Cyst. Neck CT showing second branchial cleft cyst. (Photo contributor: Scott Manning, MD.)