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branchial cleft cyst

Tuesday 9 March 2004

branchial cleft sinus, branchial cysts, branchial cleft cysts


Definition: A branchial cleft cyst is a congenital epithelial cyst that arises on the lateral part of the neck usually due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development. Less commonly, the cysts can develop from the first, third, or fourth clefts.

About 20% of cervical masses in children.

The cyst wall is composed of either squamous or columnar cells with lymphoid infiltrate, often with prominent germinal centers. The cyst may contain granular and keratinaceous cellular debris. Cholesterol crystals may be found in the fluid extracted from a branchial cyst.


- Infected branchial cleft cyst may show atypical keratinized cells.


- cervical region : cervical branchial cleft cyst
- parotid
- mediastinum : mediastinal branchial cleft cyst


- first branchial cleft cyst

  • First branchial cleft cysts are divided into type I and type II. Type I cysts are located near the external auditory canal. Most commonly, they are inferior and posterior to the tragus (base of the ear), but they may also be in the parotid gland or at the angle of the mandible. They may be difficult to distinguish from a solid parotid mass on clinical examination. Type II cysts are associated with the submandibular gland or found in the anterior triangle of the neck.

- second branchial cleft cyst

  • The second branchial cleft accounts for 95% of branchial anomalies. Most frequently, these cysts are identified along the anterior border of the upper third of the sternocleidomastoid muscle, adjacent to the muscle. However, these cysts may present anywhere along the course of a second branchial fistula, which proceeds from the skin of the lateral neck, between the internal and external carotid arteries, and into the palatine tonsil. Therefore, second branchial cleft cyst is in the differential of a parapharyngeal mass.

- third branchial cleft cyst

  • Third branchial cleft cysts are rare. A third branchial fistula extends from the same skin location as a second branchial fistula (recall that the clefts merge during development); however, a third branchial fistula courses posterior to the carotid arteries and pierces the thyrohyoid membrane to enter the larynx. Third branchial cleft cysts occur anywhere along that course (eg, inside the larynx), but are characteristically located deep to the sternocleidomastoid muscle.

- fourth branchial cleft cyst

  • Fourth branchial cleft cysts are extremely rare. A fourth branchial fistula arises from the lateral neck and parallels the course of the recurrent laryngeal nerve (around the aorta on the left and around the subclavian artery on the right), terminating in the pyriform sinus; therefore, fourth branchial cleft cysts arise in various locations, including the mediastinum.


- squamous cell carcinoma arising in a branchial cleft cyst


- 1 to 4 cm of diameter
- squamous or ciliated columnar epithelium
- lymphoid nodules beneath the surface epithelium
- less than 40 years old
- unilocular
- smooth lining
- possible atypical keratinized cells (if inflammation / infection)
- cytologically bland :

  • squamous 90%
  • respiratory 8%
  • mixed 2%

Differential diagnosis

- thymic cyst
- thyroglossal cyst
- cystic metastasis of squamous cell carcinoma SCC

  • 40+ yers old
  • multilocular
  • complex lining with intracystic papillations
  • cytologically atypical
  • usually non-keratinizing


- p16- branchial cleft cyst
- p16+ branchial cleft cyst

See also

- branchial clefts

  • branchial cleft anomalies
    • branchial sinus

- cystic lymph node metastasis