Branchial cyst sinus and fistula

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^T^^l^D: Neck swelling or discharge that arises at the site of an embryonic pharyngeal pouch.

Probably arise from congenital remnants of the 2nd pharyngeal pouch or ^^ branchial cleft, although the precise embryological origin is disputed.

^^ |a/R: Occasionally associated with 1st or more rarely 3rd/4th cleft cysts.

Branchial cysts are the most common, presenting most often in the third decade, with considerable variation, and in men slightly more often than over time, it is usually painless unless inflammation and infection develop, then becomes painful and red. A sinus or fistula presents with a neck dimple that discharges mucus or mucopurulent fluid.

E: If this is a cyst, a lump is present just deep to sternocleidomastoid at the junction of its upper and lower

On palpation the swelling is usually ovoid, smooth and firm or may be relatively soft in early stages, fluctuant and may transilluminate. 2% are bilateral. The external opening of a branchial sinus or fistula is at the junction of the middle and lower 13 of the anterior edge of sternocleidomastoid.

P: Grooves in the neck, known as branchial clefts, with the intervening branchial arches appear in the 5th week of foetal development. The 1st cleft persists as the external auditory meatus, but the remainder normally disappear. If remnants of the 2nd cleft remain, a cyst, sinus or fistula may develop slowly over years. The cysts are lined by squamous epithelium and contain collections of turbid fluid consisting of epithelial debris and cholesterol crystals, and some contain lymphoid tissue.

A fistula passes between the internal and external carotid arteries, superior to the hypoglossal nerve and inferior to the glossopharyngeal nerve terminating in the posterior part of the tonsillar fossa in the oropharynx.

I: Imaging: Ultrasound or CT scanning can be used to visualise the cyst.

FNA is used to distinguish a branchial cyst from cervical lymph node metastases in older individuals (e.g. thyroid cancer and mucoepidermoid carcinomas of salivary glands that may have a significant cystic component).

M: Surgery: Treatment is surgical excision of the cyst and any associated sinus or tract. This is usually performed via a transverse neck incision. Platysma is divided and sternomastoid is retracted posteriorly to obtain access to the cyst. It is then removed by careful blunt dissection with identification and avoiding nerve damage (especially the hypoglossal and spinal accessory nerve). A branchial cyst abscess should first be drained and antibiotics given to eliminate infection before the cyst is excised.

C: Infection, branchial cyst abscess, nerve damage during surgery, incomplete excision of a sinus or fistula tract.

P: Good, with cure following complete excision.

Patient complains of a lateral neck swelling 03 left-sided) that may vary in size

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