0:01

This was a young patient who presented with a

0:04

right sided painless neck mass without fever.

0:10

We start at the top here,

0:13

and again we go through the brain.

0:15

Looking pretty good.

0:17

Vessels of the Circle of Willis look fine.

0:19

The orbits are okay.

0:20

The paranasal sinuses are clear.

0:22

I'm going to scroll down from the aerodigestive

0:25

system, looking at the nasopharynx,

0:27

looking at the oral cavity,

0:28

looking at the oropharynx,

0:30

looking at the supraglottic larynx,

0:34

to the glottic larynx, to the subglottic larynx.

0:37

Check out the esophagus, check out the trachea,

0:40

check out the thyroid gland,

0:42

and then move to the deeper spaces of the neck.

0:45

So when we look to the deeper spaces of

0:47

the neck at the angle of the mandible,

0:49

we come into this nice round cystic lesion,

0:53

which has a thin border that is showing minimal

0:56

peripheral enhancement and is showing some mass

0:59

effect on the sternocleidomastoid muscle.

1:02

You notice that the fat here next

1:04

to it is slightly injected,

1:06

and we do have a few small lymph nodes.

1:09

Well, this is a very good location for a second

1:13

branchial cleft cyst. Again,

1:15

deep to the sternocleidomastoid muscle,

1:17

but superficial to the carotid sheath vessels and

1:22

therefore a Bailey's type 2

1:24

second branchial cleft cyst.

1:26

I'm a little bit concerned about the wall of this

1:29

cyst and to make sure that it does

1:32

not represent cystic lymphadenopathies,

1:34

especially since we have other small lymph

1:37

nodes adjacent to it. So in this situation,

1:40

we're going to pay particular attention to the oropharynx.

1:44

Remember that HPV positive oropharyngeal cancers

1:48

is a source of cystic lymphadenopathy.

1:52

Any type of squamous cell carcinoma can cause

1:55

cystic or necrotic lymph nodes.

1:57

But in this case,

1:58

we want to be in particularly concerned

2:00

about any asymmetry that we see in the oropharynx

2:04

from the tonsil to the glossotonsillar sulcus region,

2:10

which is right along here, into the base of the

2:12

tongue. And that all looks perfectly fine.

2:16

Am I sure that this is not a cystic lymph node?

2:21

Not entirely. We might suggest,

2:23

particularly with the adjacent lymphadenopathy,

2:26

that they do an aspirate of this lymph node to make

2:29

sure that it is not a squamous cell carcinoma.

2:32

And sometimes they can even do an assay for

2:34

HPV positive material in the lymph node.

2:38

We're going to continue downward.

2:39

We see again the lower border of this lymph node

2:43

is somewhat irregular and that there is adjacent

2:46

edema. This is not a lymph node.

2:49

This ended up being a second branchial cleft cyst

2:52

that did have some inflammation

2:54

secondary to being traumatized

2:57

during the time that the patient was

3:00

palpating the process.

3:01

So second branchial cleft cyst.

3:05

Differential diagnosis.

3:06

Cystic lymph node from squamous cell carcinoma,

3:10

often with HPV positive features.

Case 21 - 2nd Branchial Cleft Cyst

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