A lump/ mass on the neck - Branchial cyst

Branchial cyst is associated with swelling or discharge from the neck which originating from the embryonic sites of pharyngeal pouch.

The precise embryological origin of the branchial cyst is unsure but it may rises form the congenital remnant of the 2nd pharyngeal pouch or from the branchial cleft.

It isa associated with the 1st cleft cyst and rarely with 3rd, 2nd, 4th cleft cysts. Branchial cyst is common in third decades o life in men than in women with considerable variation.

Patient complains of painless swelling on the lateral left sides of the neck which grows in sizes . However it is painful when inflammation and infection develop on the sites. Branchial sinus or fistula will develop at a neck dimple which discharge a mucopurulent fluid or mucosal fluid.

If branchial cyst present, a lump may be feel deep at the junction of the upper and lower 2/3 of the sternomastoid muscle.

On early stages, while palpating the swelling is soft, transilluminate and fluctuant.In later stages, It is smooth, firm and oval or ovoid in shape. In 2 % of cases the swelling is on both sides ( bilateral ). At the junction of middle and 1/3rd lower of the sternomastoid muscle is the sites of branchial sinus or fistula.

During the fifth weeks of fetal development , branchial cleft present as groove in the neck present with intervening branchial arches. Only the 1st cleft remains which later develop onto external auditory meatus while the remainder disappear. If the remnant of the 2nd cleft persists, it will develops onto fistula and tract. The branchial cyst which is lined by squamous epithelium consists of turbid fluid that contain cholesterol crystal and epithelial debris and in some case may contain lymphoid tissue.

A fistula that is form will pass through external and internal carotid arteries, then superior to hypoglossal nerve and inferior to glossopharyngeal nerve before terminating at the posterior part of tonsillar fossa.

The investigation for branchial cyst include imaging and fine needle aspiration. Imaging involves ultrasound or CT- scanning to visualizes the cyst. Fine needle aspiration is useful to distinguish between branchial cyst or metastases of cancer to cervical lymph nodes in case of thyroid cancer or mucoepidermoid carcinoma of the salivary gland that affects older patient.

The treatment involves surgical approach. The surgical procedure involves transverse incision to the neck , follows by division of platysma muscle then posterior retraction of the sternomastoid muscle. The cyst is removed by blunt dissection with careful consideration not to damage hypoglossal nerve and spinal assessory nerve. If cyst abscess is present, the abscess need to be drained and antibiotic is given before cyst is removed.

The complication involves the formation of branchial cyst abscess, infection, damage to the nerve during surgery and incomplete excision of fistula and sinus.

The prognosis is good with complete cure following complete excision.

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