The Journal of Emergency Medicine, Vol. 46, No. 1, pp. e23–e25, 2014Copyright � 2014 Elsevier Inc.

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http://dx.doi.org/10.1016/j.jemermed.2013.08.044

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Visual Diagnosisin Emergency Medicine

JUST ANOTHER SORE THROAT?

Preeti Dalawari, MD, MSPH,* Matthew K. Schroeder,† and Katherine E. Foerster†

*Division of Emergency Medicine, Saint Louis University School of Medicine, Saint Louis, Missouri and †Saint Louis University,Saint Louis, Missouri

Reprint Address: Preeti Dalawari, MD, MSPH, Division of Emergency Medicine, 3635 Vista at Grand Avenue, First Floor Desloge Towers,Saint Louis, MO 63110

CASE REPORT

A 22-year-old male with a medical history of asthma pre-sented to the emergency department (ED) with sorethroat, limited head rotation to the left side, and odyno-phagia for 5 days. The patient had been seen the day be-fore at the student health clinic and prescribed antibioticsfor pharyngitis, but came to the ED for worsening symp-toms. The patient described no similar symptoms occur-ring in the past. The patient reported a subjective fever aswell as left-sided otalgia, but denied shortness of breathor difficulty swallowing secretions. Mild hoarsenesswas noted. Vital signs including temperature were withinnormal limits and the patient appeared nontoxic. Physicalexamination revealed a tender and firm left-sided cervicalmass on the sternocleidomastoid muscle from the angleof the mandible to the clavicle with palpable lymphade-nopathy. The larynx was displaced to the right. Intraoralexamination revealed a midline uvula with no peritonsil-lar bulge or tonsillar exudate.

Laboratory work showed a white blood count of 11.9with a 75% neutrophil differential and mono slide testwas negative. Axial computed tomography with contrastrevealed a 4.0 � 4.7 � 8.7 cm left parapharngyeal rim-enhancing abscess from the hyoid down to the thyroid

ovember 2012; FINAL SUBMISSION RECEIVED: 23 Mugust 2013

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gland in the left perilaryngeal and paratracheal positionwith deep jugular chain lymphadenopathy and displace-ment of larynx to the right (Figures 1 and 2). Due to theextensive nature of the abscess, otolaryngology (ear,nose, and throat [ENT]) was consulted in the ED; fiberop-tic examination noted a left-sided oropharyngeal wallbulge with displacement of the patent airway. The patientwas admitted to the hospital with a diagnosis of paraphar-yngeal abscess and started on i.v. ampicillin-sulbactam,as well as dexamethasone.

Due to the location of infection and on further inspec-tion of the CT scan the following day by otolaryngology,the patient was treated for an infected second branchialcleft cyst. Due to patient’s lack of stridor or respiratorydistress, it was thought that the patient would do wellwith i.v. antibiotics and monitoring. However, after3 days, the patient showed increased pain, swelling, ody-nophagia and a persistent fever reaching 38.2�C. He wastaken to the operating room for incision and drainage ofthe infected cyst, which yielded Streptococcus viridans.Postoperatively, the patient was continued on i.v. antibi-otics for 3 additional days, at which point he was dis-charged home in good condition on oral clindamycin for7 days.Hewas referred to follow-upwith ENT for surgicalexcision and removal of the cyst, butwas lost to follow-up.

ay 2013;

Figure 2. Sagittal view of computed tomography of the neckwith i.v. contrast. Arrows indicate abscess formationwith rimenhancement of the second branchial cyst at the level ofthe larynx. Displacement of the larynx to the right can bevisualized.

Figure 1. Axial view of computed tomography of the neckwith i.v. contrast. Arrows indicate abscess formation withrim enhancement of the second branchial cyst.

e24 P. Dalawari et al.

DISCUSSION

Branchial cleft cysts are relatively uncommon anomaliesresulting from remnants of the bronchial apparatus (1).Forming between the 2nd and 7th week of embryologicaldevelopment, persistence of the branchial apparatus canlead to the development of a cyst, sinus, or fistula (2).Branchial cleft cysts are classified based on their anatom-ical position. Approximately 90% are classified as secondbranchial cysts, most commonly identified adjacent to theupper third portion of the sternocleidomastoid musclewith a majority located on the left side of the neck (2).Because the second branchial cyst can form anywherealong the track of the cleft, it should be considered inthe differential of any parapharyngeal or lateral neckmass. Branchial anomalies originating from the thirdand fourth branchial clefts are rare, accounting for only1% to 4% of published cases, but might be more prevalentthan originally suspected (3).

Unlike sinuses and fistulas, which are commonly seenin a pediatric population, branchial cleft cysts typicallypresent between the second and third decades as a painlessmobile cervical mass (1). The cysts are slow growing,usually undetected until periods of rapid swelling causedby infection, such as upper respiratory infection, pharyn-gitis, or odontogenic infection. Symptoms such asdiscomfort, dysphasia, and dyspnea are common, de-pending on the size and position of the cyst. More worri-some symptoms can include respiratory compromise ortorticollis (4).

Second branchial cleft cysts are found near the jug-ulodigastric lymph node, and can be misdiagnosed as an

enlarged suppurative, reactive, or cystic tumor-infiltratedjugulodigastric node (5). Cystic hygroma, paramedianthyroglossal duct cyst, lymphadenopathy, thyroid disease,carotid body tumors, deep space neck infections, anda host of other diseases have been documented as po-tential mimics for branchial cleft cysts (4,6).

Branchial cleft cysts can be identified by ultrasound,computed tomography, or magnetic resonance imaging.In addition to radiological techniques, fine-needle aspira-tion cytology (FNAC) can be used to differentiatebetween branchial cleft cysts and other benign or malig-nant neck masses. The majority of cysts are lined withsquamous epithelium; lymphoid tissue may also be pres-ent (4). Although FNAC can be inconclusive in infectedbrachial cleft cysts, it can help to guide antimicrobialtherapy.

In cases such as this one, the diagnosis of an infectedbrachial cleft cyst is instrumental in preventing recurrentinfection, as surgical excision of the cyst is the treatmentof choice. However, complete resolution of inflammationwith antibiotic administration, and needle aspiration orincision and drainage are needed before surgical excision(2). Recurrence after surgical excision is uncommon at3%, but can be as high as 20% (1).

CONCLUSIONS

Although branchial cleft cysts are uncommon, they mustbe included as a possibility in the differential diagnosis ofpatients with lateral neck swelling or abscesses. Accurate

Infected Branchial Cleft Cyst e25

diagnosis is crucial in preventing recurrences and futureinfection.

REFERENCES

1. Agaton-Bonilla F, Gay-Escoda C. Diagnosis and treatment of bran-chial cleft cysts and fistulae. A retrospective study of 183 patients.Oral Maxillofac Surg 1996;25:449–52.

2. Papadogeorgakis N, Petsinis V, Parara E, et al. Branchial cleft cysts inadults, diagnostic procedures and treatment in a series of 18 cases.Oral Maxillofac Surg 2009;13:79–85.

3. Nicoucar K, Ginger R, Pope H, et al. Management of congenitalfourth branchial arch anomalies: a review and analysis of publishedcases. J Pediatr Surg 2009;44:1432–9.

4. Hart C, Opperman D, Gulbahce E, et al. Branchial cleft cyst: a rarediagnosis in a 91-year-old patient. Otolaryngol Head Neck Surg2006;135:955–7.

5. Jong-Lyel R, Myung-Whun S, Kwang HK, et al. Treatment of bran-chial cleft cyst with intracytic injection of OK-432. Acta OtolaryngolSuppl 2006;126:510–4.

6. Harnsberger E, Mancuso A, Muraki A, et al. Branchial cleft anoma-lies and their mimics: computed tomographic evaluation. Radiology1984;152:739–48.