From the Guidelines
The diagnosis of a Branchial cleft cyst should be approached with caution, as it can be difficult to differentiate from malignant cystic neck lesions, and fine-needle aspiration (FNA) should be used as the first-line modality for histologic assessment, with expedient open excisional biopsy recommended if malignancy is suspected and FNA is inadequate or benign. When evaluating a cystic neck mass, it is essential to consider the possibility of malignancy, especially in patients over 40 years old, as the incidence of cancer in a cystic neck mass increases to 80% in this age group 1. The clinical presentation of a Branchial cleft cyst can be similar to that of a malignant cystic neck lesion, making imaging characteristics suggestive of malignant processes, such as large size, central necrosis, and extracapsular spread, crucial in assessing the nature of the mass 1. Key considerations in the diagnosis and treatment of a Branchial cleft cyst include:
- Physical examination to assess the size, location, and consistency of the mass
- Imaging studies, such as ultrasound, CT scan, or MRI, to confirm the nature of the mass and evaluate for potential malignancy
- FNA as the first-line modality for histologic assessment, with repeated FNA or image-guided FNA if initial results are inadequate or benign
- Expedient open excisional biopsy if malignancy is suspected and FNA is inadequate or benign
- Complete surgical excision as the recommended treatment, with antibiotics prescribed to treat any infection before surgery, such as amoxicillin-clavulanate (875/125 mg twice daily for 7-10 days) or clindamycin (300-450 mg four times daily for 7-10 days) 1. It is crucial to prioritize the diagnosis and treatment of a Branchial cleft cyst based on the most recent and highest-quality evidence, as the incidence of malignancy in cystic neck masses continues to rise, especially in patients with HPV-positive oropharyngeal HNSCC 1.
From the Research
Diagnosis of Branchial Cleft Cyst
- The diagnosis of branchial cleft cysts can be made through clinical examination, radiology, and biopsy 2
- Fine needle aspiration cytology can be used to diagnose branchial cleft cysts, but its sensitivity is lower than that of frozen section examination 3
- Ultrasonography can be used to confirm the initial diagnosis of a cervical branchial cleft cyst 2
- Computed tomography or magnetic resonance imaging can be performed if there is concern that the lateral neck lesion is not a branchial cyst or its dimension is large 2
Treatment of Branchial Cleft Cyst
- Complete surgical excision is the treatment of choice for branchial cleft cysts 4, 5, 2
- Endoscopic resection of branchial cleft cysts is a simple, safe, and feasible procedure with minimal complications 4
- Intra-operative frozen section analysis is critical to ensure patients are offered appropriate treatment, especially in cases where there is a suspicion of malignancy 3
- Meticulous removal of the cyst can be effectively achieved with minimal risk to the facial nerve, especially in cases of first branchial cleft fistula/sinus 6