Current approach to branchial remnants in the neck

Abstract

Congenital branchial fistulas and cysts are an interesting subject in cervical pathology. There are congenital malformations with late expression in young adults that require correct diagnosis and appropriate treatment. We review essential notions of cervical embryology to understand the mechanism of occurrence of these malformations and their clinical expression. The most common cases present vestiges from the second branchial arch, with the appearance of a cystic tumor or a fistulous orifice on the anterior edge of the sternocleidomastoid muscle, at the level of the hyoid bone. Performant imagery is mandatory for appropriate diagnosis, so we recommend a cervical computed tomography (CT) scan or cervical magnetic resonance imaging (MRI) to evaluate the relations with great vessels of the neck or other lesions. The treatment implies complete surgical excision because otherwise there is a high risk of recurrence of the lesion. The differential diagnosis includes cystic lymphangioma, dermoid cyst, tuberculous adenopathy, cystic hygroma, lateral cervical cystic metastases. Histological examination is mandatory for a definite diagnosis. Also, there is a small percentage of malignancy of these malformations, but it is very important to check that all the histological diagnostic criteria for a primary branchiogenic carcinoma are accomplished. Therefore, although it is a benign cystic cervical pathology, the diagnosis and treatment must be made very accurately for a complete cure, and this review aims to summarize the current approach to branchial remnants of the neck.

Figure 1

Clinical aspect of a branchial cyst derived from the 2nd arch.

Figure 2

Clinical aspect clinic of a branchial fistula derived from the 2nd arch.

Figure 3

MRI imaging of branchial fistula presenting a reservoir under the tail of the right parotid gland. MRI: Magnetic resonance imaging.

Figure 4

(A–C) Radical ablation of the right branchial fistula, using instrumental catheterization of the fistulous trajectory.

Figure 5

Clinical and surgical aspect of a left branchial cyst in a patient aged 31.

Figure 6

Huge left branchial cyst in a female patient aged 55.

Figure 7

CT scan showing a giant branchial cyst in contact with internal jugular vein and carotid bifurcation. CT: Computed tomography.

Figure 8

Cervical MRI showing the reservoir of the branchial remnants inside the tail of the right parotid gland with hypersignal in T1 and T2 sequences because of high content in proteins. MRI: Magnetic resonance imaging.

Figure 9

(A–C) Huge left branchial cyst with six decades of evolution in an 84-year-old patient with a curious shape of the resection piece.

Figure 10

Wall of the branchial cyst with multilayered squamous epithelium and hemorrhage, rich in lymphoid tissue with germinal centers (HE staining, ×100).

Figure 11

Cystic wall with respiratory epithelium with columnar cells, at the level of the stroma lymphoid tissue, is identified (HE staining, ×200).

Figure 12

Fibrous wall with inflammatory infiltrate, with stratified epithelium and keratosis, and necrosis content (HE staining, ×40).

Figure 13

CT scan presenting a cystic lymphangioma in the left parotid region. CT: Computed tomography.

Figure 14

Left cervical dermoid cyst with yellow sebaceous content.