Does a second branchial cleft cyst require surgical excision?

Surgical Excision of Second Branchial Cleft Cysts is Recommended

Second branchial cleft cysts require complete surgical excision to prevent complications including infection, recurrence, and potential malignant transformation. 1 This is especially important in adults, where the risk of malignancy in cystic neck masses increases significantly with age.

Rationale for Surgical Management

Risk of Malignancy

• In adults, cystic neck masses have a 4-24% risk of malignancy
• This risk increases to 80% in patients over 40 years old 1
• Branchial cleft cysts can mimic or harbor malignancy, particularly in adults

Complications of Untreated Cysts

• Recurrent infections with sudden increase in size and pain 2
• Potential for rare but serious complications like internal jugular vein thrombosis 2
• Difficulty distinguishing from malignant cystic lesions on imaging or FNA

Surgical Approach Options

The surgical approach should be determined based on:

1. Location of the cyst:

   • Most second branchial cleft cysts are found high in the neck 3
   • Some may present in unusual locations, requiring specialized approaches

2. Size and complexity:

   • Standard wide local excision for most cases
   • Complete excision with clear margins is essential to prevent recurrence

3. Cosmetic considerations:

   • Traditional approach: Incision over the protruding zone
   • Minimally invasive options for cosmetically sensitive cases:
     • Endoscope-assisted excision using a posterior occipital hairline approach 4
     • Endoscopic resection through mammary areolae and axillary incisions 5

Surgical Management Algorithm

1. Preoperative assessment:

   • Imaging (ultrasound and/or CT) to determine extent and relationship to vital structures
   • Fine needle aspiration to rule out malignancy, especially in adults over 40

2. Surgical technique:

   • Complete excision of the cyst with its entire wall
   • Careful dissection to identify and preserve vital structures (great auricular nerve, carotid vessels)
   • For standard approach: incision along natural skin creases
   • For cosmetic concerns: consider endoscope-assisted approaches 4

3. Postoperative care:

   • Regular follow-up to monitor for recurrence
   • Typical follow-up period of 6-12 months 3, 4

Special Considerations

• Multilocular cysts: May require more extensive dissection but still need complete excision 3
• Infected cysts: Initial treatment with antibiotics followed by excision once infection resolves 2
• Recurrent cysts: Require more extensive surgery to ensure complete removal

Potential Pitfalls

1. Misdiagnosis: Branchial cleft cysts can be misdiagnosed as odontogenic cysts or salivary gland infections 3

2. Incomplete excision: Failure to remove the entire cyst wall is the most common cause of recurrence

3. Injury to adjacent structures: Careful surgical technique is required to avoid damage to:

   • Great auricular nerve
   • Carotid vessels
   • Internal jugular vein
   • Facial nerve branches

In conclusion, while observation might be considered in specific circumstances (very young patients, high surgical risk), the standard of care for second branchial cleft cysts is complete surgical excision to prevent complications and rule out malignancy, particularly in adults.