Abstract
Branchial cleft cyst in parapharyngeal space is a very rare occurrence. Only 0.5% of all head and neck tumours constitute parapharyngeal space tumours. It is mainly congenital but can be seen at a later age following infection. MRI is the gold standard for diagnosis. This is a case report of a 19-year-old with right sided neck swelling without any significant history. It has been excised by transcervical approach.
Keywords: Parapharyngeal space, Congenital anomaly, Branchial arch anomaly
Introduction
Parapharyngeal space tumours constitute only 0.5% of head and neck tumours. Branchial cysts are congenital malformations arising from the branchial remnants. Of these 90% arises from second branchial cleft and is seen in age group from 10 to 40 years [1]. It arises anterior to sternocleidomastoid muscle, near angle of mandible. Rarely it arises from parapharyngeal space [2], usually located in the medial aspect of the space near the retropharyngeal structure or laterally, adjacent to or involving the parotid gland [3]. Symptoms mainly depends on size of the mass and is usually asymptomatic. Sometimes patient can have sore throat, dysphagia, dysarthria, dyspnoea, and hearing loss due to middle ear effusion along with inflammation if infected [1]. Diagnosis can be made on clinical suspicion and fine-needle aspiration cytology and imaging like computed tomography (CT) scan and magnetic resonance imaging (MRI) [4]. Treatment is surgical excision of the cyst, although antibiotics can be given preoperatively if the cyst is infected [4].
A Case Report
A 19 years old male presented with right sided progressive neck swelling. It was not associated with trauma, skin changes and pain over the swelling. No swelling noticed intraorally. No history of difficulty breathing and difficulty swallowing or change of voice. No history of upper respiratory tract infection or suspicion of tuberculosis. No tingling or numbness on right upper limb.
On examination, patient’s vitals were stable. There was a swelling in the submandibular region of approximately 6 cm × 4 cm × 3 cm, smooth surfaced, globular, without any skin changes/venous engorgement, no impact on coughing, no size alteration on tensing sternocleidomastoid. On palpation no local rise of temperature, non-tender, soft to cystic in consistency, well defined margins, mobile along the horizontal axis, non-reducible, transillumination negative and no bruit heard. No bulge was seen in oral cavity or oropharynx. Examination of ear, nose was normal with intact cranial nerves.
Fine needle aspiration cytology (FNAC) was suggesting benign cystic lesion. MRI neck (Fig. 1) showed a multiloculated cystic swelling of 8.5 cm × 4.2 cm × 3 cm in the right suprahyoid neck, suggestive of type II Branchial cleft cyst. Lesion was excised by transcervical approach, preceded by proper counselling of post op scaring and chances of recurrence.
Fig. 1.
a MRI showing coronal cut of right sided branchial cleft cyst. b MRI showing axial cut of branchial cleft cyst
Incision was given over the swelling along horizontal skin crease from midline till angle of mandible. Intraoperatively, sac of 8 × 4 × 3 cm3 was delineated extending from angle of mandible superiorly till cricoid inferiorly, common carotid medially, and sternocleidomastoid laterally, excised and send for histopathological examination. The sac was removed in toto and send for histopathological examination. Haemostasis was achieved and 8 size Romo bag suction drain kept and layers sutured. Suction drain was removed on postoperative day 3. Postoperatively there was paresis of mandibular branch of facial nerve which was resolved with physiotherapy by postoperative day10. Sutures were removed on postop day 10. Postoperatively there was paresis of mandibular branch of facial nerve which was resolved with physiotherapy by postoperative day10. Histopathological examination (Fig. 2) revealed branchial cleft cyst with reactive germinal centre, flattened cyst wall with fibrosis and chronic inflammatory cells. On 6 months of follow up, patient was asymptomatic and without any recurrence.
Fig. 2.
HPE showing-branchial cleft cyst
Discussion
Branchial apparatus begins to develop during the second week of pregnancy, and by the fourth week, 5 pairs of branchial arches are formed, separated by branchial cleft, which correspond internally with branchial pouches [3]. In embryonic stage, second branchial arch overlies the second, third, fourth branchial clefts into an elongated common cavity, known as sinus of his, is obliterated after birth. Various degrees of incomplete closure of the cavity leads to anomalies of second branchial cleft. Externally the tract opens in anterior border of sternocleidomastoid at the junction of middle and lower third passing between the external and internal carotid arteries, above the cranial nerves IX and XII and entering the tonsillar fossa [2]. As this tract passes through parapharyngeal space, cysts that occur are second cleft anomalies.
Seen at adulthood with some unusual presentations- snoring without dysphagia, multiple cranial nerves affected, recurrent deep neck abscess leading to repeated aspiration and drainage procedures [5]. Our case is a male on his second decade of life with right sided neck swelling just below angle of mandible without any associated symptoms.
Diagnosis can be confirmed radiologically. CT with contrast enhancement is for the cyst’s location and extent. MRI is considered the best diagnostic imaging modality, superior in delineating the cyst’s relation to great neck vessels and essential for differentiation from commoner parapharyngeal masses [5]. In our case probable diagnosis is made by MRI neck.
The mainstay treatment of a branchial cleft cyst is elective excision due to various risk of infection, further enlargement, or extremely low risk of malignancy [6]. The external route approaches are: the submandibular route-transcervical, total parotidectomy with retromandibular dissection-transparotid, a combination of the above with a mandibulotomy [2]. Infection and abscess can warrant antibiotics prior to surgical management [4]. Aesthetically, trans-parotid and transcervical approaches are with risk of damage to lingual, facial, or hypoglossal nerves, and alteration of the temporomandibular articulation but gives a wide exposure [1]. By superficial parotidectomy approach, initial exposure of the main trunk of the facial nerve and branches, reduces the risk of facial nerve injury, as it can be intimately associated with the nerve [7]. In our case transcervical approach has been taken.
Conclusion
Branchial cleft cyst in parapharyngeal space is extremely rare and is often misdiagnosed and treated as a deep neck abscess. Though congenital in origin, it mainly presents in adults with nonspecific symptoms. MRI is gold standard to differentiate from other more common parapharyngeal lesions. Complete surgical excision is the main line of treatment for prevention of recurrence.
Acknowledgements
Nil.
Authors' Contribution
The first draft of the article was written by Dr AD. The draft was revised by Dr SD and Dr. SC. All authors commented on the previous versions of the article. All authors read and approved the final manuscript.
Funding
No funding was received for this study.
Declarations
Conflict of interest
The authors have no conflict of interest to disclose.
Ethics Approval
Our Institute Research Ethics Committee has confirmed that no ethics approval is needed for case reports.
Consent to Participate
Informed consent was received from the patient.
Consent for Publication
Informed consent was obtained from the patient to publish.
Footnotes
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