From the Guidelines
Branchial cleft cysts should be evaluated with a high index of suspicion for malignancy, especially in adults over 40 years old, and fine-needle aspiration (FNA) should be used as the first-line modality for histologic assessment, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. When evaluating a branchial cleft cyst, it is essential to consider the possibility of malignancy, as the incidence of cancer in a cystic neck mass increases to 80% in patients over 40 years old 1. The clinical practice guideline for the evaluation of the neck mass in adults emphasizes the importance of identifying patients at increased risk for malignancy and recommends a targeted physical examination, imaging, and FNA to establish a definitive diagnosis 1. Key considerations in the evaluation of a branchial cleft cyst include:
- Imaging characteristics suggestive of malignant processes, such as large size, central necrosis with rim enhancement after contrast, multiple enlarged lymph nodes, extracapsular spread, asymmetric thickness of the wall, areas of nodularity, and nonconforming nature of the cystic wall 1
- The use of FNA as the first-line modality for histologic assessment, with a sensitivity of 73% in cystic cervical metastases 1
- The importance of complete surgical excision to reduce the risk of tumor spillage into the wound and to establish a definitive diagnosis 1
- The need for a targeted physical examination, including visualizing the mucosa of the larynx, base of tongue, and pharynx, to identify potential primary malignancy sites 1 In summary, the evaluation and management of a branchial cleft cyst should prioritize the exclusion of malignancy, and a comprehensive approach should be taken to establish a definitive diagnosis and guide treatment, as outlined in the clinical practice guideline for the evaluation of the neck mass in adults 1.
From the Research
Definition and Cause
- Branchial cleft cysts occur due to a failure of involution of the second branchial cleft 2.
- They are congenital epithelial cysts that arise on the lateral part of the neck and may not present clinically until later in life 3.
Diagnosis and Management
- Fine needle aspiration cytology and frozen section examination can be used in the management of cystic neck lumps, with frozen section having a higher sensitivity of 100% compared to fine needle aspiration cytology at 75% 2.
- Surgical excision is a definitive treatment for branchial cleft cysts, and adult patients should undergo intra-operative frozen section analysis regardless of clinical suspicion for malignancy 2.
- A minimally invasive approach under local anesthesia can be used in adequately selected cases 3.
- An endoscope-assisted surgical technique can also be used for the excision of branchial cleft cysts, providing better cosmetic results without negatively affecting outcomes or increasing operative time 4.
Treatment Outcomes
- Early detection and timely management are crucial to prevent complications such as superinfection in pediatric patients with second branchial cleft anomalies 5.
- Surgical excision of the cyst and fistula, including high ligation of the fistula, can be an effective treatment to prevent recurrence 5.
- The imaging study of choice for branchial anomalies remains controversial, but computed tomography fistulography can demonstrate the complete course of the tract if a cutaneous opening is present 6.
- Treatment must be tailored depending on which branchial arch is involved and whether a cyst mass or sinus/fistula tract is present 6.
Surgical Approaches
- Complete surgical excision of the entire tract has historically been the treatment of choice for branchial anomalies 6.
- Less invasive procedures, such as sclerotherapy and endoscopic excision of second branchial cysts, and endoscopic cauterization or sclerotherapy at the piriform opening for third and fourth branchial sinuses, are being studied and show promise 6.