Branchial Cleft Cyst Anomalies 4_2

7/30/2019 Branchial Cleft Cyst Anomalies 4_2

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Branchial Cleft Cyst Anomalies: A

Pictorial Review of Their Embryologic,

Anatomical and Radiologic

Appearance Along with Treatment

Options

Alex Chau, MD

Vinh Nguyen, MD


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Disclosure

I do not now have and have not within the

past 12 months had a financial interest or

other relationship with a commercial

organization that may have an interest in

the content of this educational activity.


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Branchial Cleft Cyst

Introduction

Embryology

Anatomy Cases Branchial Cleft Cysts

Summary


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Introduction Branchial Cleft Cyst:

Benign congenital epithelial cyst

20% of cervical mass children1

Cause:

Incomplete involution of branchial cleft2

Buried epithelial cell rests

Location:

Lateral neck

Morbidity:Super infection

Mass effect

Population:

Older children and young adults


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Embryology: Branchial Apparatus

Pouch

Arch Cleft

I

II

III

IV

I

II

III

IV

Endo Meso Ecto

Pharyngeal apparatus at 4th week

Branchial Apparatus:

Arch mesoderm

Pouch endoderm

Cleft ectoderm

Eye

Olfactory PitMaxillary processMandibular archHyoid archThird arch

Magnus Manske. (March 24, 2007). Retrieved 4/15/2011 from http://en.wikipedia.org/wiki/File:Gray41.png

V, VI


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Pharyngeal Apparatus Development

Proliferation of 2nd arch caudally

7th week

Clefts involutes

Obliteration of sinus of His

Failure of involution

Cyst

Sinus Fistula

Pouch

Arch CleftI

II

III

IV

I

II

III

IV

Sinus of His

I

II

III

IV

Pouch CleftArch

I

II

III

IV

Cyst

Pouch CleftArch

Sinus

Fistula

V, VI


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Pharyngeal Apparatus Derivative3

Pouch Arch Cleft Nerve

I Eustachian tube,tympanic cavity,

mastoid air cells

Mandible, muscles ofmastication, malleus and

incus

Externalear

canal

Trigeminal (V)

II Palatine tonsil Lesser horns of hyoid,muscles of facial expression,

buccinator, platysma,stapedius, stylohyoid,

posterior belly of digastric

Sinus of

His

Facial (VII)

III Inferior parathyroid,thymus, piriform

fossa

Hyoid (greater horn & body), Sinus of

His

Glossopharyngeal

(IX)

IV Superiorparathyroid

Thyroid cartilage Sinus of

His

Vagus (X),

superior laryngeal

VI Parafollicular cellsof thyroid gland

Muscle of larynx, cricoid

cartilage

None Vagus (X),

recurrent

laryngeal


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Pharyngeal Apparatus Derivative

Arch I

Malleus

& Incus Stapes

Meckels CartilageStylohyoid

Cartilage

HyoidArch II

Arch IIIThyroid

CartilageArch IV


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Radiographic

Nonenhanced CT

Low attenuation

Contrast Enhanced CT

Well circumscribed, non-enhancing mass

Superinfected: Peripheral enhancement

MRI

T1WI: Low signal

T1WI + contrast: No enhancement

Superinfected T1WI: Peripheral enhancement

T2WI: High signal cystic lesion


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Type I BCCEpidemiology

1% of branchial cleft defect4

Middle-aged women

Clinical

Recurrent otorrhea or parotid

gland abscess

Location

Near external auditory canal

(EAC): usually posterior &

inferior

Parotid or angle mandible

Submandibular gland

Treatment

Complete surgical excision

Endoscopic cauterization

Possible

locations of

Type I BCC

Patrick Lynch. 12/23/2006. Facial Nerve Branch. Retrieved 4/15/2011 from http://en.wikipedia.org/wiki/File:Head_facial_nerve_branches.jpg
http://en.wikipedia.org/wiki/File:Head_facial_nerve_branches.jpghttp://en.wikipedia.org/wiki/File:Head_facial_nerve_branches.jpg


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Type I

History: 5- year old p/w right parotid lump

Finding:

Periparotid mass, with central fluid attenuation, mild adjacent fat

stranding and peripheral enhancement anterior to the EAC.

Impression:

Type I Branchial Cleft Cyst.


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Type I Imaging

T1. Right periparotidcystic mass

T1 + contrast:Peripheral

enhancement

T2: Cystic masswithout tract to EAC


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Type 1

T1 + contrastT1 T2 fat sat

DX:Infected Left Type I BCC.


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Branchial Cleft Cyst Type II

Epidemiology

5

95% of Branchial cleft cysts

Age 10-40

Gender nonspecific

Clinical Painless cystic mass

2nd infection: tender

Recurrent submandibular infection

SCM

Patrick Lynch. 12/23/2006. Head sagittal mouth. Retrieved 4/15/2011 from http://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpg
http://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpghttp://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpg


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Location for Type II BCCBaileys Four Subgroups

Type I:Superficial and anterior tosternocleidomastoid (SCM) muscle.

Type II:Most commonClassically anterior to SCM, lateral tocarotid space and posterior to

submandibular glandType III:

Medially between ICA and ECA, underglossopharyngeal nerve (IX) and abovehypoglossal nerve (XII)

Type IV:

Pharyngeal mucosal space

CN IX

CN XII

ICA

ECA

Path

Possible locationof a

Type II BCC

Path:Green path from supraclavicular

to oropharyngeal mucosa

Lateral to common carotid

In between ICA and ECA

Below CN IX and above CN XII


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Case I: Type II BBC.

U/S: Sagittal right cervical

region with diffuse fine

echoe mass

CT Axial: Thick walled cystic

lesion anterior-medial to SCM,

lateral to carotid space

CT Sagittal: Cystic

lesion is posterior to

submandibular gland


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Case II: Type II BBC.

Cystic mass with internal septation and peripheral soft tissue suggestive of previous

infection.

SCM

Lesion


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Type III

Epidemiology6-7

3% of Branchial cleft cysts

Childhood

Preference upper 1/3 left posterior

triangle (97%)

2nd most common lesion of posteriortriangle after lymphatic malformation

Clinical

Painless cystic mass

2nd infection: tender

Difficult to differentiate 4th BCC

SCM

Trapezius

Patrick Lynch. 12/23/2006. Head sagittal mouth. Retrieved 4/15/2011 from http://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpg
http://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpghttp://commons.wikimedia.org/wiki/File:Head_sagittal_mouth.jpg


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Type III

CN IX

CN XII

Thyroid

Cartilage

ECA

Path

Hyoid

ICA

Location Start pyriform sinus

Posterior to common or internal

carotid

Below CN IX and above CN XII

Pierces thyrohyoid membrane

Superior to laryngeal nerve

Terminate around aorta on left side

and subclavian artery on the right


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Type IV

Epidemiology6,8

Rarest,1%-2% of BCC

Mostly presents as tracts

Usually infants and childhood

Mainly left sided (90%)

Associated thyroid lobe and

thyroiditis

Difficult to differentiate 3rd BCC

Clinical

Painless cystic mass

Airway compromise

Recurrent neck abscess

Thyroiditis

Hyoid

Thyroid C.

Thyroid G.

Path

Path

Starts at pyriform sinus through

thyrohyoid membrane into left

thyroid.

Inferior to superior laryngeal nerve


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Case I of Type III vs IV BCC

Multiloculated fluid collection Involves left hemithyroid

Extends to left piriform sinusMass effect hypopharynx

Case I: 9 year old male presents with recurrent neck abscess


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Case I of Type III vs IV BCC

Endoscopic survey demonstrates aTract in the ipsilateral pyriform sinus.

Endoscopic cauterization with silver nitrate.

Type III vs IV ????Unclear because both type III and IV arise

from piriform sinus and an surgicalexploration wasnt performed to show

relationship to superior laryngeal nerve.


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Case II of Type III vs IV BCC

Case II: 5 day old male born with increasing neck mass and airway compromise.Finding:

Cystic mass with internal septation associated with the thyroid.

Mass effect with rightward deviation of airway, oropharynx and

hypopharynx


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Case II of Type III vs IV BCC

Piriform sinus tract with post-endoscopic electrocauterization

DX: Type III vs IV BCC


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Case III of Type III vs IV BCC

Axial T1 Post-contrast:

Homogenous tubular enhancement lateral to left thyroid extending to skin

Medial to SCM

Cyst not visualized

Consistent with recurrent infection of tract


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Case III of Type III vs IV BCC

Axial T2 fat suppressed:

Homogenous tubular enhancement lateral to left thyroid extending to skin.

Cyst and extension to piriform sinus not visualized

Consistent with recurrent tract infection


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Case IV of Type III vs IV BCC

Case IV: 18 year old female w/ history of I & D of neck mass presents with

recurrent neck mass, pain and fever.CT: Left hemithyroid multiloculated abscess extending to

anterior skin

U/S: Complex fluid

collection


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Case IV of Type III vs IV BCC

Barium Swallow:

Blind ending sinus from left piriform sinus

Connection with neck abscess not visualized

Post-endoscopic cauterization

Closure of sinus tract

T t t


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Treatment

Traditionally9-12:

Complete surgical excision for all 4 types ofBCC

+/- thyroid lobectomy for type 3 & 4 BCC.

Morbidity: Infection, reoccurence, andrecurrent laryngeal nerve injury.

Novel approach for type 3 & 4 BCC

Endoscopic cauterization

Electrocauterization, low power diode laser,chemical cauterization (trichloroacidic acid), andsilver nitrate

Reduce morbidity, hospital stay and cost.


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Conclusion Branchial cleft cyst is a differential for lateral

neck mass. There are four types of branchial cleft cyst.

Type I: Near EAC, parotid and angle of mandible

Type II: Lateral to carotid sheath, anterior to SCM and posterior to

submandibular gland

Type III & IV: Type III is in posterior compartment, posterior to SCM and

ICA. Both involves the piriform sinus.Depends on relationship

to superior laryngeal nerve. Understanding embryologicalorigin and the anatomical presentation will aid in accuratediagnosis

Treatment: Incision and dissection, & novelendoscopic cauterization.


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Reference

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2. Benson MT, Dalen K, Mancuso AA, Kerr HH, Cacciarelli AA, Mafee MF, Congenital anomalies of the branchialapparatus: embrylogy and pathologic anatomy. Radiographics 1992;12:942-960

3. Graham A, Okabe M, Quinlan R (2005). "The role of the endoderm in the development and evolution of thepharyngeal arches". J. Anat. 207 (5): 47987

4. Faerber E, Swartz J. Imaging of the neck masses in infants and children. Crit Rev Diag Imaging 1991;31:283-314

5. Vogl T. Hypopharynx, larynx, thyroid, and parathyroid. Magnetic resonance imaging. 2nd ed. St. Louis, Mo:Mosby-Yearbook, 1992; 1184-1232

6. Houck J. Excision of branchial cysts. Operative Tech Otolaryngeal 2005; 16:213-22

7. Cote D, Gianoli G. Fourth branchial cleft cysts. Otolaryngol Head Neck Surg 1996; 114:95-97

8. Pereira KD, Losh GG, Oliver D, Poole MD. Management of anomalies of the third and fourth branchialpouches. Int J Pediatr Otorhinolaryngol. 2004;68(1):43-50.

9. Nicoucar K, Giger R, Pope HG Jr, Jaecklin T, Dulguerov P. Management of congenital fourth branchial archanomalies: a review and analysis of published cases. J Pediatr Surg. 2009 Jul;44(7):1432-9.

10. Bernadette L. Koch Cystic malformations of the neck in children. Pediatr Radiol (2005) 35: 46347

11. Verret DJ, McClay J, Murray A Biavati M,Brown O. Arch Otolaryngol Head Neck Surg. 2004;130:465-468

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