Case: Second 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.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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