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Case 21 - 2nd Branchial Cleft Cyst

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This was a young patient who presented with a

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right sided painless neck mass without fever.

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We start at the top here,

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and again we go through the brain.

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Looking pretty good.

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Vessels of the Circle of Willis look fine.

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The orbits are okay.

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The paranasal sinuses are clear.

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I'm going to scroll down from the aerodigestive

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system, looking at the nasopharynx,

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looking at the oral cavity,

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looking at the oropharynx,

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looking at the supraglottic larynx,

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to the glottic larynx, to the subglottic larynx.

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Check out the esophagus, check out the trachea,

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check out the thyroid gland,

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and then move to the deeper spaces of the neck.

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So when we look to the deeper spaces of

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the neck at the angle of the mandible,

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we come into this nice round cystic lesion,

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which has a thin border that is showing minimal

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peripheral enhancement and is showing some mass

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effect on the sternocleidomastoid muscle.

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You notice that the fat here next

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to it is slightly injected,

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and we do have a few small lymph nodes.

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Well, this is a very good location for a second

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branchial cleft cyst. Again,

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deep to the sternocleidomastoid muscle,

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but superficial to the carotid sheath vessels and

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therefore a Bailey's type 2

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second branchial cleft cyst.

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

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cyst and to make sure that it does

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not represent cystic lymphadenopathies,

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especially since we have other small lymph

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nodes adjacent to it. So in this situation,

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

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Remember that HPV positive oropharyngeal cancers

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is a source of cystic lymphadenopathy.

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Any type of squamous cell carcinoma can cause

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cystic or necrotic lymph nodes.

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But in this case,

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we want to be in particularly concerned

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about any asymmetry that we see in the oropharynx

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from the tonsil to the glossotonsillar sulcus region,

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which is right along here, into the base of the

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tongue. And that all looks perfectly fine.

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

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Not entirely. We might suggest,

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particularly with the adjacent lymphadenopathy,

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that they do an aspirate of this lymph node to make

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sure that it is not a squamous cell carcinoma.

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And sometimes they can even do an assay for

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HPV positive material in the lymph node.

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We're going to continue downward.

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We see again the lower border of this lymph node

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is somewhat irregular and that there is adjacent

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edema. This is not a lymph node.

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This ended up being a second branchial cleft cyst

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that did have some inflammation

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secondary to being traumatized

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during the time that the patient was

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palpating the process.

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So second branchial cleft cyst.

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Differential diagnosis.

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Cystic lymph node from squamous cell carcinoma,

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often with HPV positive features.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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