Branchial Remnants and Branchial Cyst

1. Branchial Remnants
Raymond G Buick
Paediatric Surgeon
Birmingham UK
December 2008

2. Branchial Remnants
•First Branchial Cleft Cysts
•Type I
–Ectodermal Duplication anomaly of the EAC with
squamous epithelium only.
–Parallel to the EAC
–Pretragal, post auricular
–Connection with TM or Malleus>Incus
–Surgical Excision

3. Branchial Remnants
•First Branchial Cleft Cysts
•Type II
–Ectoderm and mesoderm components
–Anterior neck, superior to hyoid bone.
–Courses over the mandible and through the parotid in variable
position to the Facial Nerve.
–Terminates near the EAC bony-cartilaginous junction.
–Surgical excision- superficial parotidectomy
REFER TO ENT

4. Branchial Remnants
preauricular
sinus

5. Preauricular sinus
•The External Ear forms from a
number of tubercles.
•Failure of normal fusion may
result in a congenital sinus
•Pinpoint opening
•Maybe short symptomless
tract
•May lead to a ‘rabbit warren’ of
intercommunicating cysts in
front of the tragus
•? ENT

6. Preauricular pits
•Infected preauricular pit
•Preauricular abscess

7. Branchial Remnants
•SKIN TAGS
•These are most often benign, isolated minor anomalies,
•mostly unilateral but occasionally bilaterally.
•It is important however to examine the anatomic landmarks
carefully. If the tags are associated with distortion of the pinna
then it should trigger suspicion of associated pathology such as
the possibility of hemifacial microsomia.
•Tags may also be seen as part of multiple dysmorphic features
of infants with chromosomal anomalies.
•if isolated, no investigations are required and audiology referral
is not necessary unless there are other risk factors, particularly
a family history of hearing loss.

8. Branchial Remnants
•SKIN TAGS

9. Cartilaginous Remnants

10. Branchial Remnants
•Second Branchial Cleft Cysts
•Most Common (90%) branchial anomaly
•Classical Branchial cysts & sinuses

11. Branchial Cyst
•At the fourth week of embryonic life, the development of 4
branchial (or pharyngeal) clefts results in 5 ridges known as
the branchial (or pharyngeal) arches, which contribute to the
formation of various structures of the head, the neck, and the
thorax.
•The second arch grows caudally
•Branchial cysts arise from failure of obliteration of the second
branchial cleft in embryonic development.

12. Branchial Cyst
Branchial cleft cysts are congenital
epithelial cysts
Present on the lateral part of the
neck

13. Branchial Cyst
Branchial cleft cysts are congenital
epithelial cysts
Present on the lateral part of the
neck
Painless, fluctuant mass in anterior
triangle often behind SCM muscle

14. Branchial Cyst
Branchial cleft cysts are congenital
epithelial cysts
Present on the lateral part of the
neck
Painless, fluctuant mass in anterior
triangle often behind SCM muscle
Sinus / fistula on anterior border of
SCM at junction of middle and lower
1/3
Often VERY tiny
Sinus or
fistula Sinus or
fistula

15. Branchial Cyst
•A branchial cyst commonly presents as a solitary, painless
mass in the neck of a child or a young adult. A history of
intermittent swelling and tenderness of the lesion during
upper respiratory tract infection may exist. Discharge may be
reported if the lesion is associated with a sinus / fistulus tract.
•In some instances, patients may present with locally
compressive symptoms.
•A family history may be present.

16. Branchial Cyst
•Most branchial cysts are asymptomatic. They may
become tender, enlarged, or inflamed, or they may
develop abscesses, especially during periods of
upper respiratory tract infection, due to the
lymphoid tissue located beneath the epithelium.
•Spontaneous rupture of an abscessed branchial cleft
cyst may result in a purulent draining sinus to the
skin or the pharynx.

17. Branchial Remnants
•Second Branchial Cleft Cysts
Branchial
fistula
Branchial Fistula
orifice in
Tonsillar fossa

18. Branchial Cyst
•Treatment
•Surgical Excision
Antibiotics for infected lesions- excision
I & D may be needed initially
Ladder incision may be needed
deep to platysma,
lateral to IX, X, XII,
between the internal and external carotid
terminate in the tonsillar fossa

19. Branchial Remnants
•THANKS TO
•www.adhb.govt.nz