A 30-year-old female with no significant past medical history presents to the Emergency Department with a six-day history of an enlarging, tender, red “bump” on her anterior neck. She reports similar swelling during bouts of pharyngitis. She also reports a recent upper respiratory infection one week ago that was marked by fever, cough, congestion, sore throat, and myalgia. She denies shortness of breath, neck trauma, travel, or animal exposures.

Vitals: T 37°C; BP 122/78; HR 77; RR 17

General: Well-developed, well-nourished female in no acute distress

HEENT: 2cm tender, fluctuant, mobile right anterior neck mass with surrounding erythema; no drainage noted; mass does not move with swallowing

The remainder of the exam is unremarkable.

Non-contributory

Second branchial cleft cyst

Branchial cleft anomalies are the second most common type of congenital neck mass and present as cartilaginous remnants, sinuses, fistulas, or cysts due to the failure of the branchial apparatus to obliterate. The most common are second branchial cleft anomalies, representing 95% of these cases. Second branchial cleft anomalies are usually located along the anterior border of the sternocleidomastoid muscle on the left side of the neck.

Differential diagnoses include thyroglossal duct cyst, neck abscess, cystic hygroma, cervical lymphadenopathy, metastatic lymph nodes, and cat scratch disease.

The gold standard of treatment necessitates complete surgical excision of the entire branchial cleft anomaly. Branchial cleft anomalies are most commonly diagnosed with computerized tomography (CT) that shows a uniformly hypo-or-anechoic mass with well-defined margins and thin walls. Preoperative fine needle aspiration cytology can be used to view histopathological findings of the mass and help to rule out malignant disease. Ultrasound and MRI can also be helpful for diagnosis, preoperative localization, and preoperative identification of surrounding structures. However, for definitive diagnosis, surgical excision of the entire anomaly and pathology examination is required. If full resection is not achieved, recurrence is possible.

Take-Home Points

  • A branchial cleft anomaly is the second most common type of congenital neck mass.
  • Branchial cleft anomalies are due to failure of the branchial apparatus to obliterate and can present as cartilaginous remnants, sinuses, fistulas, or cysts.
  • The gold standard of treatment requires complete surgical excision of the entire branchial cleft anomaly to prevent recurrence.
  1. Muller S, Aiken A, Magliocca K, Chen AY. Second Branchial Cleft Cyst. Head Neck Pathol.2015;9(3):379-383. doi:10.1007/s12105-014-0592-y Zaifullah S, YunusMR, See GB. Diagnosis and treatment of branchial cleft anomalies in UKMMC: a 10-year retrospective study. Eur Arch  2013;270(4):1501-1506. doi:10.1007/s00405-012-2200-7

 

Alicia Hereford

Alicia Hereford

Medical Student
University of South Alabama
Alicia Hereford

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Michael Sternberg, MD

Michael Sternberg, MD

Professor
Department of Emergency Medicine
University of South Alabama
Michael Sternberg, MD

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